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

Sung, Il Soon; Song, Mi Ra; Kim, Hee Sun; Kim, Eun Sook; Jung, Mi A; Lee, Su Mi; Sung, Young Hee; Ha, Kook Hee; Kim, Seong Hwa; Lee, Hye Ran; An, Kyoung Jin; Shim, Mi Ok; Kim, Nag Hee; Sung, Young Hee

Journal of Korean Society Quality Assurance Health Care 2008;14(1): 49.
Published online May 30, 2008.

낙상 peer review group 운영을 통한 낙상발생률 감소

성일순¹, 송미라¹, 김희선¹, 김은숙¹, 정미아¹, 이수미¹, ¹, 하국희¹, 김성화¹, 이혜란¹, 안경진¹, 심미옥¹, 김낙희¹, 성영희²

¹삼성서울병원 간호본부
²성균관대학교 의과대학 삼성서울병원 임상간호학교실

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

Il Soon Sung¹, Mi Ra Song¹, Hee Sun Kim¹, Eun Sook Kim¹, Mi A Jung¹, Su Mi Lee¹, Young Hee Sung¹, Kook Hee Ha¹, Seong Hwa Kim¹, Hye Ran Lee¹, Kyoung Jin An¹, Mi Ok Shim¹, Nag Hee Kim¹, Young Hee Sung²

¹Dept. of Nursing, Samsung Medical Center
²Dept. of Clinical Nursing Science, Samsung Medical Center, Sungkyunkwan University School of Medicine

Abstract

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.

Key words fall;peer review;accident prevention;