낙상 peer review group 운영을 통한 낙상발생률 감소

Reduction of Fall Incidence through Operation of the Staff Nurse-Centered Peer Review Group

Background : This study was to reduce incidence of falls by analyzing actual problem and drawing out improvement plan applicable to the clinical practice through operation of the staff nurses-centered fall peer review group. Method : The fall peer review group was composed of 8 nurses having patient nursing experience for over 5 years, 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 perform immediate intervention when patient's condition changed. Based on the above-mentioned results, improvement activity was conducted for the purposes of consolidating patients education method and supplementing computerized system to support nurses' decision making as well as devices and facilities. Result : As a result of conducting improvement activity in the aspects of education for patients, support of nurse's decision-making, and devices and facilities through operation of the staff nurses-centered fall peer review group, falls decreased by 9.5% compared to before improvement activity. Conclusion : It is concluded that operation of the clinical nurses-centered fall peer review group played a role of promoter to draw out practical and applicable improvement plan to the clinical practice and apply directions of the field-centered, and increased nurses' interest in falls and ultimately, reduced incidence of falls. Therefore the Center will continue to operate the staff nurses-centered peer review group, and recommends participation of nurses who actually take the charge of nursing patients in further analysis of patients' safety accidents.