Objective:To analyze the causes of fall,make and implement relevant improvement measures.Methods:We delivered retrospective analysis of causes of 46 fall cases in our hospital in 2015.The reasons were nurses' improper assessment or not timely assessment,poor effect of health education about drug and physical activity among patients with physical disabilities,nurse visits not in place,and patients' poor compliance,etc.In order to reduce the incidence of falls,we established improvement project,including establishment of fall team,fall assessment and health education training,formulating health education manual,standardizing 5p patrol mode,using mobile logo and fall informed consent,and using quality control method to ensure the effectiveness of the project measures.Results:There were 29 fall cases in 2016,and the incidence was 0.58 per thousand.Compared to 2015,the incidence in 2016 decreased significantly (P＜0.05).The incidence of severe damage reduced significantly from 43.5％ to 10.3％.The regression analysis showed that improvement project was a protective factor for fall patients with severe damage.Conclusion:Through the analysis of the causes of fall adverse events,we can use improvement project to reduce the incidence of falls,reduce the degree of injury,ensure the safety of patients,and improve the quality of nursing.%目的:针对跌倒不良事件进行原因分析,制定并实施相关改进措施.方法:对我院2015年跌倒不良事件46例进行回顾性原因分析,得出护士评估不准确、健康教育不到位、巡视不到位、患者及家属依从性差等为主要原因,进行降低跌倒发生率的专案改善;通过成立跌倒专案改善小组,培训护士跌倒评估的方法,制定健康教育手册,规范5p巡视模式,使用移动标识和预防跌倒知情同意书,并使用质量控制方法保证措施的有效性.结果:2016年全年发生29例跌倒,发生率为0.58‰,较2015年显著下降(P＜0.05),重度损伤发生率从43.5％降低到10.3％ (P＜0.01).结论:通过对跌倒不良事件的原因分析,使用专案改善方法降低了住院患者跌倒发生率,减轻了患者伤害程度,保障了患者安全,提高了护理质量.
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