根本原因分析病人跌倒事件

Application of Root Cause Analysis for Prevention of Fall Events among Hospital Inpatients

10.6142/VGHN.22.2.125

柯彩風(Tsai-Feng Ko)；張麗銀(Li-Yin Chang)

跌倒 ； 根本原因分析 ； 跌倒傷害率 ； fall ； Root Cause Analysis RCA ； fall injury rates

榮總護理

22卷2期（2005 / 06 / 01）

125 - 131

繁體中文

本專案目的係以根本原因分析法(Root Cause Analysis, RCA)，找出某醫學中心住院病患跌倒事件傷害率偏高（89年71%）的原因。經擬訂問卷調查後有56.2%的單位表示有漏報跌倒事件情形，因此導致計算傷害率時分母縮小，此爲造成跌倒事件傷害率偏高之直接近因，經根本原因分析後顯示，跌倒事件表格複雜，護理人員教育宣導不足，未建立無懲性通報流程及防範跌倒標率與流程，爲造成跌倒傷害率偏高之主因。經改善後，跌倒傷害率於90年降至目標預訂值49.25%以下，至93年更低於世界之平均值，而跌倒發生件數亦漸降低。此成效之達成與維持主要有主管之參與支持，及團隊運作學習之效益，將繼續執行預防跌倒措施以維護病患安全。

The special report aims to demonstrate how Root Cause Analysis (RCA) was used to identify those underlying causes leading to over-estimated fall injury rates (71%) among hospital in-patients in 2000. These causes were classified into three categories: 1. Adminstrative causes-too complicated a fall event reporting form and process, chief nurses not informed, insufficient fall prevention education, shortage of health education materials, fear of being reprehended. 2. Nurses-worry about negative influence on their reputation, lacking understanding or ability to carry out the program. 3. Patients-under-reported their non-injurious falls. A task force was organized to accomplish the following objectives: 1. Design and simplify the fall event reporting form and process. 2. Standardize the guideline and flow chart of fall prevention (SOP). 3. Improve the under-reporting of fall events. 4. Promote fall prevention to reduce fall incidence rate and fall injury rate. With administrative amelioration, there was a consensus of no punishment for those who reported fall events. The staffs were encouraged to report inpatient fall events, provide safety education, and put fall prevention SOP into action. With chief staffs' involvement in and supporting the task force, the fall injury rate was reduced to be lower than our goal of 49.25%, which was the world-wide average rate. The number of fall events gradually decreased. To keep benefiting from RCA team operation, it is necessary to continue enforcing fall prevention strategies for patients' safety.