降低急性後期病人住院跌倒發生率之專案

Project to Reduce the Incidence of In-Hospital Falls in Post-Acute Care Patients

背景：跌倒是急性後期照護病房中常見且具高度危害性的事件。本單位2023年病人跌倒率為0.34％，遠高於院內品質監測指標（≤0.08％），顯示防跌措施亟需改進。
目的：本專案旨在透過跨專業合作與多元化策略，建立標準化防跌照護模式，將急性後期病房之跌倒率降至0.12％以下，以提升病人安全與照護品質。
解決方案：專案期間（2024年2月1日至6月30日），跨專業團隊共同建構並執行多元介入措施，包括：（1）建立標準化跨專業防跌流程、（2）強化衛教與照護人員賦能、以及（3）導入多項防跌輔助設備。
結果：介入後之評值期（2024年7月至8月），病人跌倒率由改善前之0.34％（2023年共24件／7，072人日）顯著降至0.06％（1件／1，561人日），優於預定目標。在後續長達一年的追蹤期（至2025年8月），成效穩定維持，並於2025年上半年達成連續六個月零發生率（0.00％）。此外，相較於2023年，2024年全年節省了1，916分鐘的額外護理時間，並降低醫療成本約新臺幣16，980元。
結論：本專案透過跨專業團隊合作，整合醫師參與衛教、復健即時介入、護理人員防跌措施與照顧者技能查核，針對高風險因子進行多元改善。執行後，急性後期照護住院病人跌倒發生率由0.34%降至0.06%，顯示系統性、個別化防跌策略能有效提升病人安全與照護品質。

Background: Falls are common and highly hazardous events in post-acute care (PAC) wards. In 2023, the fall rate in our unit was 0.34%, substantially exceeding the hospital’s quality benchmark (≤0.08%), indicating an urgent need for improvement.
Purpos: This project aimed to establish a standardized fall-prevention model through interprofessional collaboration and multifaceted strategies, with the goal of reducing the fall rate in PAC wards to below 0.12%, thereby enhancing patient safety and care quality.
Resolution: During the implementation period (February 1–June 30, 2024), an interprofessional team designed and implemented multiple interventions, including (1) establishing standardized interprofessional fall-prevention procedures, (2) strengthening health education and staff /caregiver empowerment, and (3) introducing assistive devices for fall prevention.
Results: During the evaluation phase (July 1–August 31, 2024), the patient fall rate decreased significantly from the 2023 baseline of 0.34% (24 falls/7,072 patient-days) to 0.06% (1 fall/1,561 patient-days), surpassing the target goal. In the subsequent one-year follow-up period (through August 2025), this effect was sustained, notably achieving a zero-fall rate (0.00%) for six consecutive months during the first half of 2025. Furthermore, comparing the full year 2024 to 2023, the project saved 1,916 minutes in additional nursing time and reduced medical costs by approximately NT$16,980.
Conclusions and Applications: This project implemented an interdisciplinary collaborative approach that integrated physician-led patient education, timely rehabilitation interventions, nursing-based fall-prevention strategies, and caregiver competency assessments to address multiple high-risk factors. After implementation, the incidence of falls among hospitalized post-acute care patients decreased from 0.34% to 0.06%. These findings indicate that systematic and individualized fall-prevention strategies can significantly improve patient safety and the quality of care.