目的：探讨有效降低住院患者跌倒风险因素的方法。方法：按照失效模式与效应分析（FMEA）的方法，分析预防跌倒管理流程、失效模式/潜在风险原因及风险危急值，针对分析结果改善预防跌倒管理流程，并进行跌倒预防质量控制。结果：实施干预措施和改进流程后，6项关键失效模式的RPN值均较实施前下降，差异均有统计学意义（P<0.05）；且实施后高风险患者跌倒发生率为0.57%（4/696），明显低于实施前的3.41%（10/293），差异有统计学意义（字2=9.956，P=0.002）。结论：结合FMEA和“5E”伤害预防策略改进的跌倒预防管理流程的实施有助于降低住院患者跌倒风险，为解决风险因素、有效降低跌倒发生率提供管理借鉴。%Objective:To investigate the effective methods of reducing the risk factors of falls in hospitalized patients.Method:According to failure mode and effect analysis(FMEA) method,the management process of fall prevention,failure mode/the reasons of potential risk and risk priority number were analyzed,on the analysis results,the falls prevention management process were improved,and the quality control of fall prevention was adopted.Result:After the implementation of intervention measures and improve the process,the RPN value of six failure mode were decreased compared with before the implementation,the differences were statistically significant(P<0.05), and after the implementation,the incidence of falls in high-risk patients was 0.57%(4/696),which was significantly lower than 3.41%(10/293) before the implementation,the difference was statistically significant(χ²=9.956, P=0.002).Conclusion:The fall prevention management process which is improved by the combination of “5E” injury prevention strategies and FMEA is helpful to reduce the risk of falls among the inpatients,as well as providing experience for addressing the risk factors and reducing the probability of falls.
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