本研究從個案醫院一個年度有關跌倒的報告單中，篩選出已出被評定為高危險群之住院病患，在住院期間發生跌倒事件之案例。除上述報告單之記錄外，我們並訪談25位護理人員。對於病患?已被評定為高危險群，卻仍發生跌倒之事件，故本研究的目的在於探討既有的病患評估機制、醫療、照護、病患及家屬認知與醫院之硬體設施與跌倒之關連性為何。本研究發現，跌倒前活動是發生跌倒的一個重要的訊號，所處環境對跌倒前活動是一個重要因素，更進一步，本研究發現，病患所服用藥物，照護人力，病房科別，病患及家屬認知，也是重要項目。關鍵詞:危險跌倒因子、溝通、認知 The study from a hospital was a case study which was in relation to patients’ falling event reports in a year by sieving the high risk inpatient out when the falling events occurred in the period of the hospital. In addition to the records in these reports, we also interviewed 25 care workers.The patients were already evaluated to be high risk, but the falling events still occurred. Thus, the study purpose consisted in treating the patients’ assessment which already existed. By the way, we also wanted to know the relation between falls and medical treatment, care services, the cognition between patients’ and family members and the hardware in the hospital. The study discovered the activities before falling were very important signals and the environment was also an important factor before falling. Furthermore, the study discovered the medicines which the patients took, the manpower in caring work, the sickroom, and the cognition between patients’ and family members were also important items. Keywords: fall risk factors, communication, cognition
