以根本原因分析法改善跌倒之個案研究

Protection for Patients From Falling-A Case Study via Root Cause Analysis

根本原因分析(Root Cause Analysis,RCA)是一種回溯性失誤分析之工具，經由分析瞭解造成失誤之過程及原因，進而檢討及改善程序，以減少失誤的發生。本文旨在以某醫學中心急診病人跌倒事件為例，引用根本原因分析的步驟，找出跌倒事件之近端原因有工作人員因素：護理人員未確實對病人進行高危險跌倒的評估及防範措施；設備因素：左邊床欄未完全拉起；病人因素：呼吸喘、躁動不安。並找出根本原因包括教育訓練不足、新進輔助人員對病人生活照護不熟悉、未機動安排照護人力、未建立推床定期檢修及維護制度。研擬改善措施為執行各項在職教育、調整輔助人力、推床編號並設專人定期檢測等。實施後該區未再發生由相同原因引起之跌倒事件。

Root Cause Analysis (RCA) refers to an analytical tool that allows physicians to identify the process and causes behind errors retrospectively in order to review and improve the process, thereby minimizing the occurrence of errors.Using the patient-falling incidents in an emergency treatment roomas the subject of research, this study at tempted to use RCA to find out the immediate causes leading to patient-falling incidents. The results showed as follows: (1) Workers: nurses did not thoroughly carry out all tasks related to assessment and protection of patients from falling; nurses and assistants did not provide their services sufficiently. (2) Equipment: left side rails were not lifted completely. (3) Patients: patients experienced short-breathing and irritation.The followingare the fundamental causes tobe identified: (1)Training was inadequate. (2)New assistants were unfamiliar with the care needed by patients. (3) Care-giving manpower was not arranged flexibly. (4)A bed maintenance and repair system was not in place.The following improvement measures are recommended: (1) implementing on-job training programs, (2) allocating assistants flexibly, and (3) numbering beds and checking beds regularly.All measures have been proven to be significantly effective and sufficient to protect patients from falling again.