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낙상 peer review group 운영을 통한 낙상발생률 감소
성일순,송미라,김희선,김은숙,정미아,이수미,하국희,김성화,이혜란,안경진,심미옥,김낙희,성영희 한국의료QA학회 2008 한국의료질향상학회지 Vol.14 No.1
Background : This study was to reduce incidence of falls by analyzing actual problem and drawing out improvement plan applicable to the clinical practice throughoperation of the staff nurses-centeredfall peer review group. Method: The fall peer review group was composedof 8 nurseshavingpatient nursing experience for over 5years, and each of fall cases was reviewed and the root cause was analyzed. As a result, it was found that the patients and their families did not fully understandthe content of the education, and the staff nurses did not completely inspect the risk factors of falls and performimmediate intervention whenpatient's condition changed. Based on the above-mentioned results, improvement activity was conducted for the purposes of consolidating patients education methodand supplementing computerized systemto supportnurses' decision making as wellas devicesand facilities. Result: As a resultof conducting improvement activity in the aspects of education forpatients, support of nurse's decision-making, and devicesand facilities through operation of the staff nurses-centered fall peer review group, falls decreased by 9.5% comparedto beforeimprovement activity. Conclusion : It is concluded that operation of the clinical nurses-centered fall peer review group played a roleof promoter to draw out practical and applicable improvement plan to the clinicalpractice and apply directions of the field-centered, and increased nurses' interest in falls and ultimately, reduced incidence of falls. Therefore the Center willcontinue to operate the staff nurses-centered peer review group, and recommends participation of nurseswhoactually take the charge of nursingpatients in furtheranalysis ofpatients' safety accidents.