Abstract:

Objective The clinical fall prevention information system is developed and its effect is verified，providing references for the prevention of clinical falls through information technology. Methods Based on the screening-assessment-intervention-evaluation process recommended by the toolkit，a clinical fall prevention information system was constructed through the steps of team formation and group discussion. The system includes 2 modules of fall prevention clinical practice and fall adverse event management，and 5 basic functions of fall risk assessment，structured risk point screening，personalized intervention measures，evaluation report and intervention prescription，and adverse event reporting. From September to December 2021，the system was tested in 6 departments with a high incidence of falls in a tertiary A hospital in Chongqing，and the application effect of the system was verified from 5 aspects：friendliness of the system interface，professional guidance，improvement of patient participation，reduction of fall incidence and injury rate. Results 68.9% of nurses thought that the system was user-friendly；82.7% thought that the system was professional and instructive；75.3% thought that the system could improve patients’ participation in fall prevention. After trial of the system，the incidence of falls and injury decreased，but the statistical difference was not obvious（P>0.05）. Conclusion This system realized multi-team cooperation to jointly pay attention to patients’ falls，and it was well recognized by nurses in terms of professional guidance and improving patients’ participation in fall prevention. At the same time，due to the short trial and verification time，narrow scope and small sample size of this system，its fall prevention effect needs to be further promoted and verified.

Key words: Inpatient, Fall, Prevention, Information System, Adverse Event, Nursing Care

摘要：

目的 开发临床跌倒防范信息系统并验证其效果，为通过信息化技术防范临床跌倒提供借鉴。方法 以工具包推荐的筛查-评估-干预-评价流程为框架，通过组建研究团队、小组讨论等步骤，构建临床跌倒防范信息系统。该系统包括跌倒预防临床实践、跌倒不良事件管理两大模块和跌倒风险评估、结构化风险点筛查、个性化干预措施、评估报告及干预处方、不良事件上报共5个基本功能。2021年9月—12月，在重庆市某三级甲等医院6个跌倒发生率较高的科室试用系统，从系统界面友好性、专业指导性、患者参与度、跌倒发生率及跌倒伤害率5个方面验证系统的应用效果。结果 68.9%的护士认为系统界面友好、82.7%的护士认为系统专业指导性强、75.3%的护士认为该系统能提高患者参与跌倒防范的意愿。系统试用后患者跌倒发生率及伤害率降低，但差异无统计学意义（P>0.05）。结论 该研究构建的系统实现了多团队合作共同关注患者跌倒，在专业指导性和提高患者跌倒预防参与性方面获得护士较好的认可。由于该系统试用的时间较短，范围较窄，样本量较小，其跌倒预防效果还有待进一步验证。

关键词: 住院患者, 跌倒, 预防, 信息系统, 不良事件, 护理