住院病人跌倒預防改善專案

The improvement for inpatients' fall prevention

跌倒於醫院意外事件中佔首位，因此跌倒的預防是照護上重要課題。本專案目的在探討病人跌倒的相關因子，及有效的因應措施，降低病人跌倒的發生率，經由參考相關文獻並以三現法查證，資料的分析結果發現，造成病人跌倒的主因有：一、人員對跌倒缺乏危機意識及跌倒危險因子辨識不足而未落實跌倒的評估 ；二、缺乏跌倒評估紀錄單；三、病人健康因素及使用增加易引發跌倒的藥物；四、病人及家屬對跌倒認知不足等因素。因應措施：病人跌倒相關文獻研讀及在職教育，增加人員對跌倒危險因子的辨識，落實執行跌倒評估、建立病患跌倒危險評估量表、製作警示牌、衛教海報及衛教單張，教育病人及家屬跌倒的預防，對策實施後，人員對跌倒評估完整度由36%至100%，病人跌倒發生率由0.15%降至0.08%，經專案改善後大幅提升人員對跌倒評估及預防的重視、降低住院病人跌倒率，提升照護品質。

Fall is the most common cause of accident events in hospital. Prevention of falling down is the important topic in inpatient care. The purpose of this study was to discuss the risk factors of fall and found effective methods to reduce the incidence of patient falls. Through literatures review and the data analysis disclosed the four risk factors of falls.: Frist of all, staffs were lack of alerts to risk factor identification and did not ensure the risk assessment. The second, the lack of falls assessment record sheet. The third,the health factors of patient and conditions induced by drug side effect. Finally, patients and families were lack of knowledge about falls. The nursing intervention include staffs join the literatures review and discussion reeducation to increase the ability of fall risk factors indentification complete the risk assessment, and setup the fall risk assessment tools, make warning billboard, provide education paper to patients and families for falls prevention. After the above precautions during this research, the completion of falls assessment rate increased from 36% to 100%. The inpatient falls incidence rate reduced from 0.15% to 0.08%. The quality of nursing care was proved effectiveness in this study.