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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
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.
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.
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;
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