住院病患的意外事件中，「跌倒」的發生率常居首位，為有效的控制意外事件發生， 首先即需由預防跌倒發生著手。為使同仁們能早日發現病患具跌倒之潛在性問題，本專案特 依神經科病患之疾病特性，建立趺倒危險因子評估表,擬訂跌倒防治的標準流程，於84年3 月開始在神經外科病房執行預防病患跌倒之監測，其監測的結果顯示:(一)預防報備的正確性 平均為93.59%，比83年度之56.6%改善甚多;(二)跌倒發生率有三個月高於所訂之0.1%閾 值，但逐漸下降中;(三)在防治措施的有效性方面，只有3月份未達閾值外，餘均明顯的進步 中，平均達93.07%。未來，為使跌倒發生率降低，我們將依臨床需要修改跌倒危險因子評估 表，並做信效度分析，使表格更具推廣性;建立跌倒防治模式及護理標準,持續執行監測計劃， 發現及改善問題，以降低住院病患意外事件的發生。

　　　　　According to an incident report of the medical center, patient's falls are the No.1 cause of accidents in the patient population. Therefore, how to prevent patients' falls was the top pripority to ensure the patient's quality of care. This study was designed according to the characteristics of neurosurgical patients by using a "Fall risk factor assessment score" to identify patients at risk of falls; to establish protocol for preventing patients' falls; and through the process to educate nurses to detect high risk of patients fall. The audit of patients' falls began at the neurosurgical ward in March 1995. The results showed: (1) The average of the accuracy of reporting high risk patients for fall was 93 .59 % which was much improved from the data of 56.6% 1994. (2) The incident rate of patients' fall was below threshold which was 0.1 % except 3 months. (3) The effectiveness of prevention intervention was 93.07%, which was also remarkably improved over the data of 1994. In the future, we would revise the "Fall risk factor assessment score" and test the reliability to ensure the accuracy of the tool. Also, we would establish the standard of care for preventing patients' falls and continue monitoring the process to reduce the incident rate of falls.