住院患者跌倒的根本原因分析及防范对策  

The root cause analysis of falls in hospitalized patients and related countermeasures

作　　者：张雨燕 杨茜[2] 王家兰[2] 周红梅 黄丽芳 夏蕊 马婧 ZHANG Yuyan1 YANG Qian2 WANG Jialan2 ZHOU Hongmei2, HUANG Lifang2, XIA Rui2, MA Jing2(1Yunnan University of Traditional Chinese Medicine, Kunming , Yunnan, 650500 ; 2. Department of Nursing, Yunnan Provincial Hospital of Traditional Chinese Medicine, Kunming, Yunnan, 650021)

机构地区：[1]云南中医学院,云南昆明650500 [2]云南中医学院第一附属医院,云南省中医医院护理部,云南昆明650021

出　　处：《中西医结合护理（中英文）》2018年第8期84-87,共4页Journal of Clinical Nursing in Practice

摘　　要：目的探讨患者住院期间发生跌倒的原因,为医院制定有效的跌倒伤害防范对策和护理措施提供参考。方法采用根本原因分析法(RCA)对59例跌倒事件进行回顾性研究。结果在跌倒的患者中,年龄≥60岁、女性、内科、护理级别Ⅱ级、风险评估为非高危、无跌倒史、正在服用镇静药或降糖药或降压药、完全自理和部分依赖、有陪护的患者占比更多。患者跌倒地点多发生在卫生间(35. 59%),常与排便后体位改变有关(27. 12%),跌倒时间则以夜间(18:00~8:00)为主(45. 76%)。结论住院患者跌倒的根本原因包括高龄、疾病、用药、自理能力、排便后体位改变及夜间护理人力资源不足等,制定的防范对策包括加强护士培训、加强对患者及陪护的管理、环境设施改善等,从而预防和减少患者跌倒的发生,确保住院安全。Objective To investigate the causes of falls in hospitalized patients, and to pro- vide related prevention and nursing countermeasures for the hospital. Methods Totally 59 falls in hospitalized patients were retrospectively analyzed by using root cause analysis. Results Pa- tients over 60 years old, female patients, from internal medicine clinics, with grade 2 nursing, with non-high-risk evaluation, without history of falls, with medication of sedative or hypotensive drugs, with full or partial self-care, with care service by caregivers were more vulnerable to falls. About 35.59% falls occurred in the bathroom, 27.12% falls due to the body position change after defecation. About 45.76% falls occurred at night time （ 18：00 - 8：00 ）. Conclusion The falls in hospitalized patients may related to senility, disease, medication, self-care ability, body posi- tion change after defecation and inadequate number of nurses at night time. It is required to en- hance the training of nurses, strengthen the management of patients and caregivers, and improve the environment and facilities, in order to reduce the risk of falls in hospitalized patients.

关 键 词：住院患者 跌倒 根本原因分析法 护理管理 自理能力 

分 类 号：R473.5[医药卫生—护理学]