跌倒為病人安全通報常見之異常事件，不僅造成病人的身體傷害、增加住院天數甚至死亡， 也帶給醫療體系及家庭龐大的照護負擔。本專案旨在降低住院病人傷害性跌倒發生率，調查本院 四個內外科病房於2015 年及2016 年第一季傷害性跌倒高達14 件( 發生率60.9%) 與3 件( 發生 率50%)，其中重度跌倒件數各為3 件與2 件，導因為護理人員執行預防跌倒正確率偏低、未啟動 跨團隊合作機制、病人及照顧者不清楚自身為跌倒高風險群、缺乏多元的預防跌倒衛教工具。透 過舉辦預防跌倒教育訓練、建置電腦螢幕跌倒高危評估及介入措施提示、與新入院病人共同評估 跌倒因子及共擬防跌計畫、組織跨團隊防跌共同照護網、張貼預防跌倒警示海報及床邊衛教單張， 經介入措施實施後，2016 年第三季傷害性跌倒發生率降至0%，重度傷害0 件。顯示本專案在臨 床運用確實可降低傷害性跌倒之發生，可提供各醫療機構推展預防跌倒實務之參考，有助於維護 病人住院安全及提升照護品質。

Falls are incidents commonly seen in the patient-safety reporting system. They can cause physical injuries and can lead to an increase of length of stay or even death. They can also bring a huge burden to the healthcare system and a family. This project aims to lower the injurious falls incidence among inpatients. It finds that the injurious fall incidents out of four internal medicine and surgical wards in the hospital in the first quarters of 2015 and 2016 reach staggering numbers of 14 (incidence: 60.9%) and 3 (incidence 50.0%), respectively, among which 3 and 2, respectively, are categorized as severe. This is because the accuracy rate of the nursing staff performing falls prevention is low; the mechanism of interdisciplinary team work is not launched; the inpatients do not realize that they themselves are at high risk for falling or the caregivers do not realize that the cared are at high risk for falling; and the diversity of healthcare education tools for falls prevention is insufficient. After the interventions with such solutions as training sessions held for falls prevention, and establishment of computerized monitoring system and intervention guidance, and joint falling factors analysis for new inpatients, joint development of falls prevention programs, organization of interdisciplinary joint care network, and posts of falls prevention posters and bedside healthcare education flyers, the injurious falls incidence in the third quarter of 2016 drops to 0.0%, showing that this project is clinically effective in lowering injurious falls incidence and can serve as an example for other medical institutions to promote their falls prevention practices and to protect the safety of stay and quality of care for their inpatients.