本研究由研究者與某署立醫院護理之家實務工作者合作組成行動研究團隊，以護理之家住民為研究對象，研究期程自2005年3月至2005年12月。本研究採取行動研究法，運用中華民國長期照護專業學會六項品質指標中跌倒指標作為監測標準，以每3個月為一期，從回溯資料中找出欲改善之問題開始，藉由不斷的反思、研擬行動策略、執行和評值，期能讓護理之家住民得到最高品質的照護。研究結果顯示，某署立醫院護理之家，住民跌倒率由2005年1月至2005年3月間護理之家住民跌倒發生率0.34％（24人次）降至2005年10月至12月之 0.24％（17人次），有效提昇該護理之家之照護品質。

This study was aimed at investigating the quality of care in fall in a nursing home in order to prevent infection and enhance quality of care for the nursing home residents. An action research was conducted by a team of researchers and nurses from the nursing home.The team members used reinforcement, empowerment, participation observation, and focus group in-depth interviews to identify problems, conduct data collection and data analysis. The procedure of this study was a cyclic process of continuous review, discussion, self-criticism and outcome evaluation. Data analysis indicated that average percentage of fall declined from 0.34% between January and March, 2005 to 0.24% between October and December, 2005, which was an important indicator of quality improvement in the nursing home.