血液透析門診病人跌倒發生率高之改善專案

Improvement Project for High Incidence of Patient Falls in Hemodialysis Outpatients Clinics

於2012 年護理部16 件跌倒異常事件中，以本單位發生4 件居冠，除了造成病人身體傷害之外，其中一件重度傷害醫院亦付出龐大醫療資源，有鑒於血液透析病人跌倒危險傾向及傷害均高於一般族群，故引發動機成立專案小組降低血液透析門診病人跌倒發生率，經現況分析、確立問題為環境中危險因子多、預防跌倒衛教方法不敷需求、護理人員未確實執行防跌措施，經由研擬對策，去除環境危險因子、修訂防跌照護作業標準、舉辦在職教育，增加活潑、生動之衛教單張及海報、製作模擬情境防跌衛教光碟、舉辦團體衛教講座及護理人員執行預防跌倒落實度定期稽核等解決方案，不但有效降低跌倒發生率由0.009％ 降至0.002％，達到專案目標，亦提升病人安全及護理照護品質。

Amongst the 16 abnormal fall events that occurred in the Department of Nursing in 2012, the greatest number of abnormal fall events occurred in this division. In addition to the patient harm they caused, one of the four events resulted in a serious injury that wasted an enormous amount of the hospital’s medical resources. Hemodialysis patients are more prone to falling and injury so a task force was established to reduce fall incidence among patients of the hemodialysis outpatient clinic. Analysis showed that the problems included risk factors present in the environment, insufficient patient education on fall prevention, and nurses failing to perform fall-prevention measures. Strategies and solutions were formulated to solve these problems: removal of environmental risk factors, standardization of fall-prevention nursing procedures, organizing of on-the-job-training, more vivid and attractive educational handouts and posters, creation of patient educational DVDs for fall-prevention in simulated scenarios, organizing of group patient education forums, and regular inspections on the execution of fall-prevention measures by nurses. These solutions effectively reduced fall incidence from 0.009% to 0.002% and fulfilled the project goal. Patient safety and nursing quality were also enhanced.