某地區醫院內科病房住院病患跌倒意外事件之改善方案

Improving Project of in the Community Hospital

李健月(Chien-Yueh Li) ； 謝美慧(Mei-Hui Hsieh)

《東港安泰醫護雜誌》 12卷2期 (2006/06) Pp. 81-95

https://doi.org/10.7078/TSMHMNJ.200606.0081

摘要

住院病患的意外事件中「跌倒」的發生率常居首位，為有效的管理意外事件的發生，首先即需由預防跌倒發生著手。為使同仁們能早日發現病患具跌倒的潛在性問題，本專案以某地區醫院為例，發現跌倒事件佔所有意外事件的46.1%，其中以內科病房為最高佔35.8%，其跌倒發生率為0.14%，對此不良現象針對該單位護理人員進行問卷，發現以下問題：(1)沒有足夠的工具來評估病人是否容易跌倒、(2)沒有足夠的工具衛教病人預防跌倒、(3)病人覺得我的衛教方式不能達到預防跌倒的發生、(4)病人不能了解配合我所衛教的內容、(5)經過護理照護和衛教後，病人仍有跌倒情形發生。因此針對以上問題的解決方法：(1)擬定跌倒危險因子評估表；(2)建立預防跌倒標準作業流程；(3)制定「高危險性傷害/跌倒」護理計畫表；(4)製作「小心跌倒」警示牌，作為提醒病患及家屬。設定改善目的為護理人員能確實衛教預防跌倒的措施，降低跌倒的發生，保障病患的安全。經四個月努力的結果，使得跌倒發生率從0.14%降低至0.087%，並希望藉由專案的改善，提昇護理人員對病人安全的重視。

關鍵字

跌倒 ； 住院病患 ； 改善

並列摘要

The number one accident happened in the in-patients is falls. The effective way for controlling this accident is preventing the falls. The data of this study was collected and analyzed from a community hospital.
In this hospital the incidence of in-patient falls was showed 46.1% in all accidents, and the highest incidence was 0.14% that happened in medicine ward. The incidence of falls in this study was higher than the average rate 0.03%.
The factors that are related to patient fall was found in this study including: (1) lack of effective assessment tool, (2) lack of education program, (3) invalidation of education strategy, (4) uncooperative from the patients to the education, (5) patients falls after nursing care and education. The intervention of this study are as following: (1) to set up assessment tool, (2) to build the standard operating procedure (SOP), for prevention of patient falls, (3) to establish care plan sheet, (4) to make a warning card to remind patients and their family. The result of this study indicated that the falls incidence decreased from 0.14% to 0.087% after the intervention for 4 month. Implement a fall reduction program and evaluate the effectiveness of the program might reduce the risk of patient harm resulting from falls.

並列關鍵字

falls ； in-patient ； improving