跌倒是急診室常見之病人安全問題之一，此問題發生不僅直接造成病人身體上的傷害、延長住院天數、導致死亡率上升及增加醫療體系及家庭的照護負擔，間接的還可能導致醫療糾紛的產生、醫病關係的惡化。
急診跌倒發生率亦是醫院需維護的重要品質指標之一，為預防急診跌倒事件的發生，各家醫院多針對個別性的跌倒事件進行根本原因分析(Root Cause Analysis)來解決跌倒的問題，鮮少透過檢視醫院的預防跌倒流程上的不足來預防。本研究目的透過醫療照護失效模式及效應分析(Healthcare Failure Mode and Effect Analysis，HFMEA)方式來檢視急診室預防跌倒流程，探究流程未周全之處，找出系統上的問題並改善。
本研究採回溯性研究，分析急診室2013年至2017年的跌倒發生率皆高於醫院跌倒閾值(0.1%)，研究團隊運用HFMEA管理手法檢視預防跌倒標準流程，發現共有8項失效模式，25項失效原因。研究團隊在急診室主任的帶領下，成立跨科室的預防跌倒團隊，執行相關的預防措施及因應策略，其中包括預防跌倒課程的共識訓練、急診個案的預防跌倒跨科室會診、急診跌倒高危個案的居家訪視、急診跌倒高危個案的遠距居家復健等措施。此改善前、中、後統計花了一年的時間，使得跌倒發生率由2017年的14件降至2018年的3件，低於醫院跌倒閾值。本研究透過預防跌倒流程的改善及跨團隊的合作，成功的降低急診跌倒發生率，並提升急診病人就診安全及醫療照護品質。

Fall incidents are a common patient safety problem in emergency rooms. Such incidents cause patients to experience physical wounds, prolong their hospitalization, increase their likelihood of early death, and impose additional burdens to their family members. In addition, fall incidents can potentially lead to medical disputes and undesirable physician–patient relationships.
The fall occurrence rate is a crucial indicator for maintaining healthcare quality in hospitals. To prevent fall incidents, various hospitals have adopted root cause analysis on the fall incidents of patients of different sexes. However, few hospitals have inspected the shortcomings in their fall prevention procedures. This study adopted the healthcare failure mode and effect analysis (HFMEA) to examine the fall prevention standard operation procedure (SOP) of an emergency room , identify shortcomings in the procedure, and develop improvement strategies to address related problems.
A retrospective research design was employed to analyze the fall occurrence rate in the emergency room between 2013 and 2017, and the results revealed that this figure was higher than the hospital threshold (0.1%). The research team of this study used the HFMEA to examine the fall prevention SOP and identified 8 failure modes and 25 failure causes. Under the supervision of the emergency room director, the research team formed a cross-department fall prevention team to execute related prevention measures and response strategies. These included fall prevention consensus training, cross-department fall prevention consultation, home visit services for emergency room patients with high risks of falling, and telerehabilitation home services for emergency room patients with high risks of falling. Statistics before, during, and after the implementation of related measures were compiled over a course of 1 year. This reduced the number of fall incidents from 14 in 2017 to 3 in 2018, yielding an occurrence rate below the hospital threshold. Through improvement to the fall prevention SOP and cross-department collaboration, this study successfully reduced the fall occurrence rate of an emergency room and enhanced the patient safety and healthcare quality.

論文審定書．．．．．．．．．．．．．．．．．．．．．．．．．．．．．ⅰ
誌謝．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．ⅱ
中文摘要．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．ⅲ
英文摘要．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．ⅳ
第一章 緒論．．．．．．．．．．．．．．．．．．．．．．．．．．．．1
第一節 研究背景與動機．．．．．．．．．．．．．．．．．．．．．．1
第二節 研究目的．．．．．．．．．．．．．．．．．．．．．．．．．2
第二章 文獻探討．．．．．．．．．．．．．．．．．．．．．．．．．．2
第一節 醫療照護失效模式與效應分析．．．．．．．．．．．．．．．．2
第二節 跌倒定義．．．．．．．．．．．．．．．．．．．．．．．．．3
第三節 造成急診室跌倒相關因素．．．．．．．．．．．．．．．．．．3
第三章 醫院現況分析．．．．．．．．．．．．．．．．．．．．．．．．7
第一節 單位組成簡介．．．．．．．．．．．．．．．．．．．．．．．7
第二節 預防病人跌倒相關作業規範與作業流程．．．．．．．．．．．．7
第三節 單位跌倒發生率及通報案例原因分析．．．．．．．．．．．．．9
第四章 研究方法．．．．．．．．．．．．．．．．．．．．．．．．．．14
第一節 主題選定與名詞定義．．．．．．．．．．．．．．．．．．．．14
第二節 成立醫療照護失效模式與效應分析團隊．．．．．．．．．．．．15
第三節 研究架構與作業流程圖．．．．．．．．．．．．．．．．．．．15
第四節 執行危害分析．．．．．．．．．．．．．．．．．．．．．．．18
第五節 對策擬訂及執行．．．．．．．．．．．．．．．．．．．．．．30
第五章 效應與執行結果分析．．．．．．．．．．．．．．．．．．．．．40
第一節 改善效果確認．．．．．．．．．．．．．．．．．．．．．．．40
第二節 研究創新手法：居家預防跌倒介入成效分析．．．．．．．．．．44
第三節 流程規範化及效果維持．．．．．．．．．．．．．．．．．．．48
第六章 結論與建議．．．．．．．．．．．．．．．．．．．．．．．．．49
第一節 研究限制與建議．．．．．．．．．．．．．．．．．．．．．．49
第二節 研究價值與未來發展．．．．．．．．．．．．．．．．．．．．49
參考文獻．．．．．．．．．．．．．．．．．．．．．．．．．．．．．．51
附錄一 預防病人跌倒作業準則修訂前後全文對照表．．．．．．．．．．．54
附錄二 人體試驗倫理委員會臨床試驗同意證明書．．．．．．．．．．．．61

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