降低門診病人跌倒發生件數及傷害率之專案改善

A Project to Reduce the Numbers of Falls and Injury Rates in the Outpatient Department

醫院意外事件發生比例以跌倒最高，跌倒會增加病人、家庭與社會負擔且易造成潛在醫療糾紛。個案醫院門診區2019年發生15件跌倒且傷害率高，造成2件重度傷害為股骨骨折手術、輪椅翻覆致顱內出血入加護病房，故成立專案小組，本專案目的為降低門診病人跌倒發生件數及傷害率，經分析發現病人跌倒主要原因為病人缺乏跌倒認知、護理師缺乏教育訓練、防跌宣導工具不足及缺乏安全設備和環境；組員參考文獻、發揮創意擬定對策，包括規劃在職教育、團體衛教、多媒體設備宣導及設置安全環境設備。實施改善對策後，跌倒件數由15件降為4件、傷害率由66.7%降為0%並達效果維持，本專案小組經分析與改善進一步提供病人安全之就醫環境，盼此專案可作為其他相同屬性單位參考。

Patient falls are the most common adverse events reported in hospitals, which increase the burden on patients, families, and society, and can easily lead to potential legal problems. Our outpatient department had 15 cases of falls with a high injury rate in 2019, resulting in two severe injuries: femoral fracture surgery and intracranial hemorrhage due to wheelchair overturning requiring admission to the intensive care unit. Therefore, a task force of quality improvement team was established with aim for reducing the number of falls and the injury rate among patients in the outpatient department. After literature review and team discussion, we found that the main causes of patient falls were lack of fall awareness among patients, insufficient education and training for nurses, inadequate fall prevention tools, and lack of safety equipment and environment. From 2020-1-1 to 9-30, the quality improvement team had used a lot of strength to formulate the effective strategies, which included planning in-service education, group health education, multimedia device promotion, and installation of safety environmental equipment. After implementing the improvement strategies, we have performed the quality improvement program from 2020-10-1 to 2021-9-30. After devoted a lot of endeavors in this year, the number of falls decreased from 15 cases (before intervention) to 4 cases (intervention period), and the injury rate decreased from 10 cases (66.7%) to zero cases (0%).This study demonstrates that application of quality improvement program may be useful in reducing the number of falls and the injury rate. Furthermore, the project team may probably provide a safe medical environment for patients. We sincere hope that this project can serve as a reference for other similar units.