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

낙상 peer review group 운영을 통한 낙상발생률 감소

  • Sung, Il Soon (Dept. of Nursing, Samsung Medical Center) ;
  • Song, Mi Ra (Dept. of Nursing, Samsung Medical Center) ;
  • Kim, Hee Sun (Dept. of Nursing, Samsung Medical Center) ;
  • Kim, Eun Sook (Dept. of Nursing, Samsung Medical Center) ;
  • Jung, Mi A (Dept. of Nursing, Samsung Medical Center) ;
  • Lee, Su Mi (Dept. of Nursing, Samsung Medical Center) ;
  • Sung, Young Hee (Dept. of Nursing, Samsung Medical Center) ;
  • Ha, Kook Hee (Dept. of Nursing, Samsung Medical Center) ;
  • Kim, Seong Hwa (Dept. of Nursing, Samsung Medical Center) ;
  • Lee, Hye Ran (Dept. of Nursing, Samsung Medical Center) ;
  • An, Kyoung Jin (Dept. of Nursing, Samsung Medical Center) ;
  • Shim, Mi Ok (Dept. of Nursing, Samsung Medical Center) ;
  • Kim, Nag Hee (Dept. of Nursing, Samsung Medical Center) ;
  • Sung, Young Hee (Dept. of Clinical Nursing Science, Samsung Medical Center, Sungkyunkwan University School of Medicine)
  • 성일순 (삼성서울병원 간호본부) ;
  • 송미라 (삼성서울병원 간호본부) ;
  • 김희선 (삼성서울병원 간호본부) ;
  • 김은숙 (삼성서울병원 간호본부) ;
  • 정미아 (삼성서울병원 간호본부) ;
  • 이수미 (삼성서울병원 간호본부) ;
  • ;
  • 하국희 (삼성서울병원 간호본부) ;
  • 김성화 (삼성서울병원 간호본부) ;
  • 이혜란 (삼성서울병원 간호본부) ;
  • 안경진 (삼성서울병원 간호본부) ;
  • 심미옥 (삼성서울병원 간호본부) ;
  • 김낙희 (삼성서울병원 간호본부) ;
  • 성영희 (성균관대학교 의과대학 삼성서울병원 임상간호학교실)
  • Published : 2008.05.30

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.

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