跌倒的預防是現今醫療品質促進中的一環。本單位安全通報之首為跌倒事件，2015 年跌倒事件造成病人中度傷害亦讓院方付出鉅額賠償，故成立本專案小組深入探討，運用多元策略以降低血液透析門診病人跌倒件數。經現況分析後確立問題：病人透析後肢體無力、病人跌倒認知不足、護理師未正確執行預防跌倒措施、透析環境動線不良。2016 年 5 月至 12 月執行改善方案：制作電子衛教單張、評估表電子化及修訂照護作業標準、舉辦教育課程、設計透析中運動並製作光碟、去除環境危險因子等解決方案，降低跌倒發生件數由 8 件至 1 件，血液透析門診病人預防跌倒認知由63.6％提升為 90.3％，護理師執行血液透析門診病人跌倒預防的完整性由 62.1%提升為 100％，達到專案目標，有效提升病人安全及護理照護品質。

Prevention of falls is a key component promoting quality of care today. Most of the safety reports filed by this unit are fall events. In 2015, the hospital paid a huge compensation to a patient who suffered moderate injury due to a fall, and led to the formation of an ad hoc group to explore multiple strategies to reduce fall incidents in hemodialysis outpatients. After completing the analysis the following problems were found: limb weakness often occurs after dialysis, patient awareness regarding falls was inadequate, nurses neglect fall prevention measures, and poor design of the dialysis center. The following measures for improvement were implemented from May to December 2016: creation of electronic educational leaflets, revision and creation of e-assessment forms for operating standards of care, conduction of educational courses, designing and publication of exercise regimen during dialysis, removal of environmental risk factors, etc. Fall incidents fell from 8 to 1; awareness regarding fall prevention among hemodialysis outpatients increased from 63.6% to 90.3%; the completion rate of fall prevention measures by nursing staffs increased from 62.1% to 100%. Project goal was reached, and effectively improved patient safety and raised the quality of nursing care.