跌倒是醫院常見的病人安全事件之一,且醫策會已將「預防病人跌倒及降低傷害程度」,列為醫療品質及病人安全八大目標之一。本單位2018年1月至2018年12月跌倒率發生率高達0.53%(閾目標值為0.37%)。分析主要原因為照顧者無法確實陪伴、病人步態不穩又執意下床或活動、照顧者移位技巧不熟悉或不正確、照顧者認為自己可以,故未適時尋求協助,因此,藉由成立專案小組,共同分析原因及檢討,擬定:舉辦防跌分享會、床欄套、肌力訓練、設計專科性防跌單張及影片,以及設計QR code等策略,跌倒發生率可由0.53%下降至0.23%,照顧者防跌措施執行率可由60.0%上升至83.3%,可見預防跌倒成效顯著。
The incidence of falls is one of the most common patient safety events. Therefore, "fall prevention and injury reduction" have been listed in the Annual Patient Safety Goals of year by the Joint Commission of Taiwan. There is a total of 0.53% (target value: 0.37%) fall rate occurred in our unit from January to December in 2018 due to the caregivers' lack of company, insufficient knowledge of displacement, without seeking assistance timely because of being too confident, and the patients' unsteady gait insisting on walking. Therefore, we analyzed and found out what went wrong by creating a special team, and we planned to hold a sharing seminar of falls prevention, which provided bedside rails and strength training, and designed fall-related knowledge posters, videos, and QR code. The fall rate of patients in the hospital decreased from 0.53% to 0.23% and the rate of falls preventive measure increased from 60.0% to 83.3%. The objective was achieved in falls prevention.