住院病童跌落改善專案

A Project on Improvement of Fall Prevention in Hospitalized Children

本專案為某醫院兒科病房住院病童跌落之改善專案。以2009年發生11件（0.071%）跌落事件進行系統分析，確立問題為家屬對床上跌落認知、警覺性不夠；娃娃車／輪椅使用說明未有一致性的標準；現有設備無法滿足病童及家屬需要。計劃執行於2010年1月15日至2月28日，依可行、經濟、效益等選出對策八項：加強衛教及提供暫時托顧，隨著追蹤家屬對設備使用情形、制作預防跌倒衛教執行記錄卡，落實家屬汰換時之衛教、制定安全床罩使用時機（對象）、更新安全警告標語、製作提醒海報張貼在病房內、製作娃娃車／輪椅使用安全衛教標準、製作五點式防跌安全袋、申請2人共乘娃娃車。於2010月3月1日～8月31日期間，評值結果跌落發生率為0.052%，已達到專案改善目標。

This paper describes an improvement project of fall prevention for pediatric patients during hospital stay. 11 fall incidents were documented in the pediatric ward of a hospital. Root cause analysis was used to identify factors. Identified problems were （1）children's family members did not recognize, or were not alert to the children at risk of fall out of bed；（2）instruction on the use of trolley or wheelchair was not standardized；（3）current safety eequipment did not meet children and their family's needs. Eight interventions were selected to implement with consideration of their feasibility ,cost, and effectiveness. Implementation period was from January 15 to February 28, 2010. Eight activities include reinforcing family education with provision of temporary child care, frequent monitoring the use of equipment, developing a documentation card for fall prevention education, enhancing family educationwhen caregivers are changed ,establishing a criteria for the use of safety bed covers, updating the sign for safety precaution, designing fall-alert poster, defining education standard for safe trolley use, developing a 5-point belt for trolley use, and applying for purchase of double-seated trolleys. Fall incidence rate was dramatically decreased to 0.052% after implementation of eightactions. The goal of the fall prevention improvement project was achieved.