跌倒會危害到老年人健康及生活品質，並增加醫療負擔。單位2011 年1 月1 日至12 月31 日 異常事件通報以病患跌倒12 件最多，發生率0.09 %。本專案目的為降低病患跌倒發生率。病患 跌倒主要原因：病患下肢肌力評估未納入常規跌倒危險因子評估；病患及主要照顧者無跌倒防範 意識；防跌計畫缺乏下肢肌無力相關之措施及病室內環境造成病患跌倒。解決辦法包括1. 修訂跌 倒危險因子評估表；2.1 提供愛的叮嚀小卡；2.2 增設離床紅外線警示鈴；2.3 設計「生理需求特別 照護單」；3. 執行預防跌倒肌力訓練及4. 改善浴廁內排水孔、更換防滑係數高的地板及拖地標準 作業流程。結果單位病患跌倒發生率由0.09 % 降至0.05 %。此專案對護理業務的貢獻是以跨領域 團隊合作模式提供病患防跌措施並將下肢肌力列入跌倒高危險評估因子。

Falls damage the health and quality of life in the elderly people and increase the medical burden. From January 1 to December 31, 2011, twelve incidents of patient falls (0.09%) were reported by the unit. The objective of the project was to reduce the incidence of patient falls. The main reasons for patient falls were as the following: 1. The evaluation of patient’s lower-extremity strength was not included in the routine risk factors of fall assessments. 2. Lack of awareness of fall prevention among patients and the caregivers. (3) No interventions for lower-extremity weakness in the fall prevention program. (4) The ward environment causes patient’s fall. Solutions included: (1) amending the risk factors for fall assessment form; (2.1) providing the reminder cards for nursing care; (2.2) installing ultrared alarm bell when a patient leaves his or her bed; (2.3) designing a form for “care provision for special physiological needs”; (3) implementing a strength training program for fall prevention ; and (4) making improvement of drainage holes in the bathroom, replacing higher slip coefficient floors, and updating the mopping standard operating procedure. As a result, the incidence of falls at the unit declined from 0.09% to 0.05%. The contribution of this project to nursing practice lies in fall prevention assessments provided by a multidisciplinary care team and the inclusion of lower extremity muscle strength as a factor in evaluating the risk factors for falls.