根因分析法在老年患者跌倒管理中的应用

目的：探讨根因分析法（RCA）在老年患者跌倒中的应用及效果。方法：应用RCA对住院老年患者跌倒个案进行调查分析，确定根本原因，制定并落实改进措施，比较应用RCA前后的实施效果。结果：应用RCA前后老年患者跌倒发生率有统计学差异（P〈0.05），跌倒率由3.12‰下降到了0.92‰。结论：RCA对预防老年患者跌倒管理具有很好的导向作用。保证环境设施安全是预防跌倒的前提；强化系统安全建立是预防跌倒的根本；指导训练老年患者良好的健康行为是预防跌倒的关键；合理配置夜班护理人力资源是预防跌倒的主要手段。

The application of Root Cause Analysis in the fall management among the elderly patients

Objective：To explore the application of Root Cause Analysis （RCA） in the fall management among the elderly patients. Methods：We applied the principle of RCA to determine the root causes of the falls in hospitalized elderly patients, developed and implemented improvement measures, and compared the effects before and after the application of RCA. Results：Incidence of fall in the elderly patients dropped from 3.12‰to 0.92‰after the application of RCA and the difference had statistical signiifcance （P〈0.05）. Conclusions：RCA has a remarkable guiding role in elderly patients fall prevention. Ensuring the safety of environment facilities is the precondition of fall prevention. Strengthening system security is prime in fall prevention. Training elderly patients with good health behaviors is the key to prevent falls. The rational allocation of night shift nursing staff is the main method to prevent falls.