住院病人跌倒發生率改善專案

The Project on Improvement of the Inpatient Fall Rate

本單位2009-010年跌倒發生率攀升平均0.055％，超出0.02％之閾值，甚至發生死亡傷害，引發專案動機希望降低住院病人跌倒發生率。經問卷調查原因分析：由於護理品質監測系統多重易致跌倒藥物之評估項目不足、缺乏肌力及平衡評估工具、陪伴者常輪替及缺外語衛教單張，導致護理人員對服用易致跌倒藥物之病人遺漏評估、肌力及平衡評估技巧不足，對輪替的陪伴者未給予衛教；加上外傭看不懂衛教單張、輪替陪伴者對預防跌倒未交接，導致陪伴者預防跌倒認知不足；另外病室止跌設備不足等。專案於2011年8月14日至2012年6月14日實施，擬定及執行改善對策包括：護理品質監測系統新增評估易致跌倒藥物項目，及建立簡易肌力及平衡評估表，並進行教育訓練；訂定陪伴者預防跌倒交接表及漸進性下床步驟圖卡，翻譯四項外語版跌倒衛教單張（印尼文、越南文、英文、日文），並執行陪伴者衛教；裝置浴室防滑墊及病室扶手等設備。自2011年11月8日起迄今跌倒發生率降為0.013％，傷害率為0，達專案目標。透過專案建立了跌倒評估高危險群之規範，更強化陪伴者預防跌倒觀念、落實病人安全預防跌倒作為。

In 2009-2010, the incidence of falls increased by an average of 0.055%, which not only caused injuries, but also death. Because of this phenomenon, medical professionals are highly motivated to intervene and establish a preventive task force. According to analysis, nurses encounter diffi culties in implementing health education because various family members typically take turns caring for patients or patients are accompanied by foreign caregivers with whom communication is challenging. Moreover, because 84.6% of high-risk patients who were administered drugs that cause falls were not included in the assessment, and simple cognitive strength assessments were not conducted in our previous study, the goal of this study was to reduce the incidence of falls and the degrees of injury. From August 14, 2011, to June 14, 2012, we revised the identification of unit falls by formulating a high-risk assessment form, translated a health consultation sheet into\ four foreign languages, educated colleagues to recognize drugs that cause falls, promoted the use of a simple muscle assessment tool, and implemented a handover table for caregivers. The results showed that, in 2013, the incidence of fall-related injuries decreased to 0.013%, and that the overall degree of damage was 0%. In conclusion, through this project, we established a nursing staff capable of assessing patients groups at a high risk of falling, developed a system for enhancing the fallprevention knowledge of primary caregivers, and implemented safety precautions to patient falls.