醫策會於2018年至2019年將「預防病人跌倒及降低傷害程度」列為醫院病人安全工作目標第四位，本單位在2017年跌倒發生率為0.117%，居全院第10名，衝擊病人安全與團隊成員的士氣，引發動機成立專案小組急迫改善病人跌倒的問題，本專案目的為降低住院病人跌倒發生率，經分析發現病人跌倒主要原因為護理人員對預防跌倒認知不足、未確實執行跌倒評估及防跌策略；病人及家屬缺乏危機意識以及無稽核制度。透過建立收案及稽核制度，落實危險評估，設計入院流程、口訣及警示牌，強化護理人員在職教育，舉行家屬及病人團體衛教等解決策略，專案實施後在2018年跌倒發生率降至0.071%。本專案護理師在預防跌倒中扮演舉足輕重的角色，護理師啟動防跌機制，與醫療團隊成員密切共同合作，達到事半功倍的效果，有效改善住院病人跌倒發生率及降低病人因跌倒造成之傷害，達到提升病人安全之目標。

High incidence of fall impact the patient safety a lot. According to the analysis of causes of falls suggested that insufficient prevention knowledge of fall of nursing staff, not exactly implementation of fall assessment and preventive strategies, and absence of an audit system; the patients and their families, in turn, also lacked crisis awareness. This project aimed to reduce the fall rate of patients within the hospital. The improvement strategies included: (1) implemented an in-service education course of preventing fall, (2) conducted standardized admission procedures and employed warning signs of fall in bedside, (3) established an auditing program, and (4) providing nursing education for high-risk patients and their families. The results revealed that the fall rate of patients in the hospital from 0.117% in 2017 decreased to 0.071% in 2018. This project was initiated by nursing staff and required teamwork to reduce the incidence of falls. This emphasizes the contribution of the nursing profession.