目的：本研究目的為：從「人」、「事」、「時」、「地」、「物」五個層面，探討個案醫院住院病人發生跌倒事件的原因。方法：本研究採回溯性資料分析，資料蒐集對象為某一教學醫院，時間為民國98年7月1日至12月31日止，總計跌倒通報事件共有55筆。結果：經由分析比較得知，多數病人屬於第一次跌倒，且男性多於女性，年齡則以65歲以上的年長者居多，而病人本身活動能力以部分依賴為主。此外，絕大多數的病人平日身邊是有照顧者陪同，且醫護人員也多有事先告知病人或家屬防止跌倒的注意事項。跌倒發生地點則多位於病房，時間以凌晨4:00~5:59為最多，若以三班制來分的話，大部份的跌倒事件是發生於大夜和小夜兩個班別。若再更進一步的探討可以發現，其跌倒的原因多跟病人本身的健康因素有關。結論：病人身邊即使有家屬陪同，並不能保證病患絕對安全，護理人員除了應加強病患及陪伴者預防跌倒的認知及衛教外，更應留意高危險群病患之身理狀況與活動狀態，及適當評估陪伴者預防跌倒及照護病患的能力，以減少院內跌倒事件的發生。

Objectives: This study explored the factors influencing inpatient falls from the perspectives of people, events, time, place, and tools.Methods: A retrospective study was conducted by analyzing reporting data of falls between 1st July and 31st December 2009. A teaching hospital was selected and a total of 55 inpatient falls were analyzed.Results: The study found that most of these inpatients had fallen for the first time. There were more males than females and the majority were over 65 years old. The motility of patients was rated as partially dependent. Most inpatients were usually accompanied by caregivers and healthcare workers had informed inpatients or their relatives beforehand about how to prevent falls. Most falls happened in ward areas from 4:00 to 5:59 in the morning. The reasons for falling down were related to health issues. such as dizziness caused from diseases. Over 80% inpatients with no using any tools (mobility aides) when falling.Conclusions: It cannot be assumed that inpatients will be safe when they have relatives accompanying them. Nurses need to educate patients and their caregivers about fall prevention. In order to reduce the occurrence of inpatient falls, they must pay attention to the motility and physical status of high-risk patients and evaluate the ability of caregiver to prevent falls.