跌倒預防一直是醫療機構重要的課題。本單位2012 年病人 跌倒發生率為0.12%，較國內醫療機構平均發生率0.06%高出許 多，因此成立專案小組進行改善。本專案目的為降低病房病人跌 倒發生率，經確認問題：病人及照護者跌倒預防認知不足、護理 人員教育訓練不足、缺乏衛教工具及稽核制度。改善措施：以團 隊的方式，醫師參與病人跌倒預防教育、病人過去及現在用藥檢 視及用藥檢討，錄製「跌倒預防宣導錄音帶」、製作彩色圖文衛 教本、提示海報、「防跌鈴鐺繩」、稽核跌倒預防護理措施及舉辦 在職教育。改善後跌倒發生率降至0.08%，病人及照顧者跌倒預 防認知完整率由33.8%提升為81.2%，本專案不但有效降低了病 人跌倒發生率,也提升了病人住院安全。

Fall prevention has been an important issue of medical institutions. The fall incidence rate was 0.12% in our unit , significantly higher than the other domestic medical institutions(0.06%) in 2012, therefore, the group was developed to improve . The aim of this project was to lower the fall incidence among ward inpatients. The contributing factors, such as: lack of knowledge about preventing fall of patients and caregivers, lack of education and training of nurses, lack of health education tools and audit system. Measures for improvement included: team approach, physician participation in patient fall prevention education, look at medical history and current medication, reviewing medication ,develop of fall prevention propaganda tapes and fall prevention handbook with color graphic, educational poster exhibition, design the "Fall Prevention bell ", monitoring procedure ,staff education. After improving the incidence rate of falls had been reduced to 0.08%, The awareness of falling among patients and caregivers increased from 33.8% to 81.2%, The project team not only decreased the falling events but also improved patient safety in hospital.