背景：罹患精神疾病的個案在健康維護與生活安全會感受到較大的威脅。近年來長期居住在機構中的住民隨著年齡增長、疾病特性以及藥物鎮靜作用影響，發生跌倒的意外事件次數增加。目的：本專案旨在降低精神障礙住民跌倒發生率，改善目標由0.0015%降低至0.0012 %，以避免意外事件的傷害。解決方案：自2011年1月1日至12月31日，透過專案成員的內部觀察、研讀文獻、會議討論以及文件整理，歸納出本機構住民預防發生跌倒因素可分為四大方面，從（一）照顧人員：提供防跌教育之專業知能；（二）住民面：增強參與體適能活動動機、接受定期藥物副作用的評估；（三）照護環境：營造安全生活環境；（四）制度面：汰換老舊輔具並定期確認輔具安全、落實防跌制度之行政管理。結果：精神障礙住民跌倒發生率為0.0007%，達成專案目標；並完成專案內容的四個核心方向的任務。結論：本專案提供精神疾患住民於機構內發生跌倒意外事件之問題檢討與改善策略，可做為未來照顧之參考。

Background: Individuals with mental illness are highly vulnerable to personal health and safety threats. In recent years, the increasing incidence of accidental falls among residents of long-term care facilities has been attributed to aging, disease symptoms, and sedative drug effects.Purpose: This project aimed to reduce the fall incidence rate for mentally ill residents in our hospital from 0.0015% to 0.0012% in order to reduce patient injuries and avoid the long-term health consequences of these injuries.Resolution: This project was conducted between January 1st, 2011 and December 31st, 2011. Our approach included direct observation, literature review, meeting discussions, and data compilation. The intervention composed four facets: (1) Staff: providing education and training skills to prevent patient falls; (2) residents: enhancing patient motivation to keep physically fit and assess medication side effects; (3) environment: increasing living condition safety; (4) policy: replacing defective equipment, performing equipment checks on schedule, and managing a fall-prevention programResult: The post-intervention fall incidence rate for mentally ill residents was 0.0007%, which was significantly better than our target.Conclusion: We reviewed plans and improved the fall-prevention strategy for mentally ill residents of long-term care facilities. This project provides a reference for care program planners and administrators.