本專案旨在改善復健科病房跌倒傷害率，運用根本原因分析（root cause analysis），確認復健科病房跌倒傷害率高之原因為：l.照服員未依規範執行業務、2.外傭對衛教內容不了解、3.未規劃步行區、4.對清潔班清潔步驟未制定規範，專案成員依據根本原因擬定具體改善方案包括：於新病人入院時，衛教照服員防範跌倒注意事頂；製作印尼語之防範跌倒衛教光碟，規畫步行訓練區，進行地線標示，並加註印尼語之標示；統一清潔工清潔抽屜流程，提供無障礙空間，使復健科住院病人跌倒傷害率由80％降至25％，藉此專案提醒同仁照護病人時，除了進行衛教，還需確認內容病人及照顧者是否能夠了解，方能達到降低跌倒傷害率及提升病人的照護品質。

Our rehabilitation ward instituted an initiative to reduce injury rate due to falls. Using Root Cause Analysis, we found the causes of high injury rate due to falls to be 1. caregivers not following regulated procedures while caring for their patients, 2. foreign caregivers do not completely understanding instructions for care, 3. a rehabilitation walking area not being established, and 4. cleaning procedures not being standardized. Project members concluded that the injury rate could be improved by providing caregivers instructions for preventing falls, making a CD for the prevention of falls for Indonesian caregivers in the Indonesian language, and establishing a walking area with Indonesian indicators on the ward floors. Procedures for cleaning drawers were standardized to create a barrier-free space. These measures resulted in an injury rate change, from 80% to 20%. This project underscored the necessity of not only providing instructions for care but also the necessity of making sure they are understood by everyone. Thus, the rate of injuries due to falls were reduced and patients were made safer.