跌倒是病人安全中發生率最高之意外事件，且造成病人傷害及增加醫療支出，本院精神科急性病房住院病人平均跌倒發生率0.09%遠高於全院0.06%，經現況分析出病人因藥物副作用及肢體軟弱而跌倒，確立本單位跌倒防範標準流程欠完整病人對跌倒防範的認知不足、多重藥物使用、環境設備不足等問題。為達到降低本院精神科急性病房病人跌倒發生率，經修訂跌倒防範標準流程並宣導改善措施、進行環境修建、醫療小組討論藥物調整、制定衛教工具以執行團體及個別指導等解決辦法後，跌倒發生率降至0.04%。雖然精神病人急性症狀不穩定、遵從性低，在調整藥物劑量與防範跌倒上增加許多照護困難，但維護病人之安全、增進照護品質為持續不斷之努力目標。

Accidental falls are highly prevalent, resulting in injury and increased medical expenditure. The accidental falling rate for acute psychiatric inpatients was 0.09%, much higher than 0.06% for all inpatients in Taichung Veterans General hospital. Drugs adverse effects and related limbs weaknesses were identified as major factors. The standard operation procedure (S.O.P.) and inpatients' awareness for falling prevention are inadequate. In order to prevent accidental falls, we modified the S.O. P. for falling prevention and education, improved the ward environment, conducted team discussion for medication adjustment, and provided psycho-education via group and individual approaches. After implementation of the program, the rate of falls was lowered to 0.04%. Although unstable psychotic symptoms and poor compliance of acute psychiatric inpatients are great challenges for medication adjustment, falling prevention, and nursing care, improving patients' security and quality of care remains an ultimate goal to achieve in the future.