降低某區域醫院住院病人跌倒發生率－－專案報告

A Project to Reduce Fall Incidence of Inpatients in a Regional Hospital

跌倒事件一直是各醫療院所相當重視的病人安全議題，研究指出跌倒事件的發生，不但影響病人的安全，延長住院天數、降低出院後的活動力，甚至引起死亡。本院2017年跌倒發生率為0.065％，住院病房區成人跌倒發生率高達0.088％，均高於THIS同儕值的0.063％，稽核護理人員預防跌倒正確率為76.4％，故透過品管圈進行改善，訂立改善目標，跌倒發生率降至≦0.060％，稽核正確率上升至90％。為瞭解問題成因，本圈以資料文件查閱、現場觀察與事件分析等方式進行資料收集，並以三現原則佐以文獻查證確立真因，並增加「教育宣導」、「護病共同照護模式」、「環境與工具」、「建立稽核制度」四大對策群組進行改善。評值結果，跌倒發生率降至0.057％，護理人員預防跌倒正確率為97.2％。檢視本次改善，除透過強調防跌衛教之重要性、增加現場作業稽核，提升病人及照顧者的警覺性外，邀請醫療與病人／家屬共同維護病人安全亦為重要議題，未來應持續落實建立醫護共同參與照護之文化，從而推展建構安全的防跌環境，降低跌倒的發生與傷害。

Falls in hospitalized patients have been a concerning safety issue in acute care hospitals. Previous research shows that the occurrence of falls affects patient safety, prolongs length of stay, reduces mobility level after discharge, and even results in death. The overall incidence of hospitalized adult patients and medical adult patients in 2017 was 0.065% and 0.088%, respectively. These data were higher than peer incidence, being 0.063%, reported to the Taiwan Healthcare Indicator Series(THIS) system. The accuracy of auditing nursing staff on fall prevention was 76.4%. By launching the quality control circle activity and setting improvement objectives, the incidence of falls reduced to less than 0.060%, and the accuracy of audit increased to 90%. To further investigate the causes of falls, we conducted data collection by doing retrospective medical record reviews, case analysis, and on-site observation using the Three-Gen Principle (genba, actual place| genbutsu, actual thing| genjitsu, reality) which was based on the checklist developed from literature review. We further established four strategies for improvement: ''Advocacy and Education'', ''NursePatient Shared Care Modality'', ''Environment and Tools'' and ''Audit System Establishment''. The findings showed that the incidence of falls was 0.057% and the accuracy in fall prevention carried out by nursing staff was 97.2%. The results of this improvement strongly indicated the importance of health education on fall prevention, on-site audit of its operation, and increasing prevention awareness among patients and caregivers. Encouraging shared efforts between medical staff and patient and patient´s family to prevent fall events was also essential. In the future, we will continue to encourage the shared care culture among physicians, nursing staff and caregivers for the ultimate goal of creating a safer environment to prevent and reduce the occurrence of fall and fall-related injuries.