研究目的:探討末期照護單位病人跌倒導因及建立安寧緩和單位預防跌倒的照護作業標準,降低跌倒發生率。材料與方法:團隊資源管理TRM的核心概念,包含領導(事前簡報)、溝通(篩出高危病人)、守望(個別化防跌措施)、互助(團隊成員)等四大構面。採前後測調查,分析單位2011年16位跌倒病人,病人的基本特性、身體狀況、社會環境,並運用Haddon matrix工具分析導致跌倒原因。結果:跌倒導因包含:下肢虛弱、藥物副作用、如廁需求、床欄被拉下及無人陪伴。經導因分析後提出:(1)發展預防跌倒團隊資源管理(2)制訂個人化預防跌倒措施(3)制訂安寧病房預防跌倒作業標準。經過6個月措施執行後,跌倒發生率從0.33%降至0.08%。結論:透過團隊資源管理達到末期病人預防跌倒,提供病人安全照護之參考。
Purpose: To establish a prevention program and to reduce the rate of falls in terminal patients. Methods: This project used a pre-test and post-test design to measure the rate of 16 terminal patients, and the cause of fall accidents with Haddon Matrix tool. Data collection included patients' characteristics, physical conditions and social environments. Team resource management (TRM) includes: leadership (brief), situation monitoring (select high risk patient), communication (personal intervention), and mutual support (team approach). Results: The main cause of fall events includes weakness of the lower limbs, side-effects of medicines, needs for going to toilet, bed fence putdown, and lack of caregivers. The fall prevention program includes: (1) Developed a fall prevention TRM; (2) Set up a personalization fall prevention protocol; (3) Establish a fall prevention guideline for terminal patients. After 6 months implementation, the rate of falls decreased from 0.33% to 0.08%. Conclusion: The fall prevention TRM has effects on terminal patients, and demonstrated apparent benefits on patient' safety.