運用根本原因分析法以降低住院病人跌倒之專案

Application of Root Cause Analysis for Prevention of Fall Events among Hospital Inpatients

目的：某醫學中心胃腸肝膽科病房2013年跌倒發生率0.214％，推行ITI客製化防跌措施後，於2014年降為0.113％，維持成效期間，於2015年4月發生病人因跌倒重度傷害事件，進行RCA，防止錯誤再發生，且將跌倒發生率降至全院閾值（0.1％）以下。方法：運用根本原因分析步驟，找出事件近端原因包括護理師未正確評估跌倒風險、未依ITI標準裝置離床報知機等，總醫師簽床未考量病房人力、職代經驗不足等，根本原因為：教育訓練、職代行政經驗不足。經瞭解失誤過程及原因後，擬出改善措施：舉辦離床報知機教育訓練、ITI防跌措施定期稽核、加強職代訓練、明訂醫師簽床辦法等。結果：實施後，專案病房跌倒發生率降至0.082％，ITI執行完整率提升至75.8％，並沒有再發生由相同原因引起的跌倒事件。結論：透過根本原因分析進行改善行動，持續安排防跌教育課程及人員訓練，使人員皆能接受RCA教育訓練，具備資料收集、檢討、原因分析和辨別預防方法能力，以維持防跌成效並持續追蹤，提升病人安全與照護品質。 Background/Aim: The annual incidence of slip and fall accident in 2013 at one Gastroenterology/Hepatology ward of a tertiary medical center was 0.214%. After the adoption of individualized tailored intervention (ITI) program, the annual incidence decreased to 0.113% in 2014. Unfortunately, a serious fall event occurred in April, 2015. Therefore, we conducted this root cause analysis aiming to identify the attributing causes and further decrease the incidence of slip and fall accident incidence targeted less than 0.1%. Methods: By root cause analysis, possible factors attributing to slip and fall accident were identified, including inappropriate risk assessment by nursing staff, setting bed-exit alarm system without obeying standard operation procedure (SOP), and inadequate communication with medical doctors. Root causes were insufficient nursing and executive training of nursing members and inappropriate use of facility and human resources. Following the analysis, we designed several programs for improvement including standard setting of bed-exit system, widely application of ITI, adequate educational training of nursing staffs and intensified communication with medical doctors to allow appropriate use of facility or human resources. Results: After the implementation of the above programs, the annual incidence of slip and fall accident decreased to 0.082%. Fully executed ITI rate to prevent fall accident was 75.8%. During follow up period, no slip and fall accident caused by same reason occurred. Conclusions: Our study demonstrated that attributing factors to slip and fall accident can be identified by root cause analysis. After the implementation of improvement programs with multifaceted consideration and regularly check up, safety of inpatients and nursing quality can be augmented by significantly reduced fall accident.

Background/Aim: The annual incidence of slip and fall accident in 2013 at one Gastroenterology/Hepatology ward of a tertiary medical center was 0.214%. After the adoption of individualized tailored intervention (ITI) program, the annual incidence decreased to 0.113% in 2014. Unfortunately, a serious fall event occurred in April, 2015. Therefore, we conducted this root cause analysis aiming to identify the attributing causes and further decrease the incidence of slip and fall accident incidence targeted less than 0.1%. Methods: By root cause analysis, possible factors attributing to slip and fall accident were identified, including inappropriate risk assessment by nursing staff, setting bed-exit alarm system without obeying standard operation procedure (SOP), and inadequate communication with medical doctors. Root causes were insufficient nursing and executive training of nursing members and inappropriate use of facility and human resources. Following the analysis, we designed several programs for improvement including standard setting of bed-exit system, widely application of ITI, adequate educational training of nursing staffs and intensified communication with medical doctors to allow appropriate use of facility or human resources. Results: After the implementation of the above programs, the annual incidence of slip and fall accident decreased to 0.082%. Fully executed ITI rate to prevent fall accident was 75.8%. During follow up period, no slip and fall accident caused by same reason occurred. Conclusions: Our study demonstrated that attributing factors to slip and fall accident can be identified by root cause analysis. After the implementation of improvement programs with multifaceted consideration and regularly check up, safety of inpatients and nursing quality can be augmented by significantly reduced fall accident.