根本原因分析病人跌倒事件

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

本專案目的係以根本原因分析法(Root Cause analysis，RCA)，找出某醫學中心住院病息跌倒事件傷害牟偏高(89年71%)的原因﹒紐擬訂問卷調奎復有56.2%的單位表示有漏報跌倒事件情形，因此導致計算傷害率時分母縮小，此為進成跌倒事件傷害率偏高之直接近圈，經根本原因分析後顧示，跌倒事件表格複雄，護坦人員教育宣導不足，未建立無傳性通報流程及時範跌倒標準典流程，為造成跌倒傷害率偏高之主因﹒經改善後，跌倒傷害率於90年降至目標預訂值49.25%以下，至93年是低於世界之平均值，而跌倒發生件數亦漸降低。此成效之達成典維持主要有主管之參典支持，及團蹲運作學習之放益，將繼續執行預時跌倒措施以維護病患安全。

The special report aims to demonstrate how Root Cause Analysis (RCA) wasused to identify those underlying causes leading to over-estimated fall injury rates(71 %) among hospital in-patients in 2000. These causes were classified into threecategories: 1. Adminstrative causes - too complicated a fall event reportingform and process, chief nurses not informed, insufficient fall prevention education,shortage of health education materials, fear ofbeing reprehended. 2. Nurses- worryabout negative influence on their reputation, lacking understanding or ability tocarry out the program. 3. Patients- under-reported their non-injurious falls. A taskforce was organized to accomplish the following objectives: 1. Design and simplifythe fall event reporting form and process. 2. Standardize the guideline and flowchart of fall prevention (SOP). 3. Improve the under-reporting of fall events. 4.Promote fall prevention to reduce fall incidence rate and fall injury rate. Withadministrative amelioration, there was a consensus of no punishment for those whoreported fall events. The staffs were encouraged to report inpatient fall events,provide safety education, and put fall prevention SOP into action. With chief staffs'involvement in and supporting the task force, the fall injury rate was reduced to belower than our goal of 49.25%, which was the world-wide average rate. The numberof fall events gradually decreased. To keep benefiting from RCA team operation, itis necessary to continue enforcing fall prevention strategies for patients' safety.