背景：本單位發生透析病人如廁時，因步態不穩跌坐在地造成股骨骨折進行手術住院治療，利 用根本原因分析調查並成立專案小組改善。目的：期望達成護理師執行跌倒評估與流程步驟完 整率100°%，跌倒事件為0件。方法：經現況分析及歷年跌倒事件發生之案例，確立問題為： 缺乏透析病人下床預防標準作業、護理師缺乏在職教育、未有足夠護理人力及家屬支援、缺乏 預防跌倒指導活動、缺乏安全的如廁動線環境。組員參考文獻、發揮創意擬定對策，包括制訂 跌倒評估與預防流程、制訂跌倒風險評估表、制訂病人如廁作業指引、規劃在職教育、規範支 援方式、護理指導活動與團體衛教及安全環境。結果：經由實施改善對策後，跌倒事件於評值 期0件並達效果維持，護理師執行跌倒評估與流程步驟完整率100%。結論：本專案重建跌倒 風險評估作業，提升家屬參與病人安全照護及醫療團隊為照護品質改善的凝聚力。

Background: In our dialysis unit, the hemodialysis patients received surgery for femoral fractures due to fall to the ground caused by unsteady gait while toileting. Aim: We hope to achieve the fall assessments and complete process steps by nurses are 100%, and fall events are 0. Methods: The identified problems by situation analysis and previous fall events are that the lack of get out of bed prevention in dialysis patients, the lack of in-service education in nurses, the lack of nurse staffing and family support, the lack of guidelines for fall prevention, and the lack of safe toilet moving line environment. The crews develop creative responses, including formulate fall assessment and prevention process, formulate fall risk assessment form, develop patient toileting practice guidelines, develop in-service education plan, develop support plan and nursing care program and group health education, and a safe environment by references. Results: After the implementation of improvement program, fall events on evaluation period was 0 and maintained, and nurses performing fall assessments and complete process steps were 100%. Conclusions: The program reconstructs the fall risk assessment works and enhances the cohesion of families to participate in patient safety and health care team to improve the quality of care.