目的:探讨根因分析法在加强在老年疗养人员跌倒管理中的应用价值。方法:采用根因分析法对杭州市五云山疗养院老年疗养人员跌倒个案进行分析研究,找出主要原因,并制定有针对性的防范管理措施,以根因分析法实施前后老年疗养人员跌倒率为评价指标,研究根因分析法的实施效果。结果:根因分析法实施以前(2015年3~11月),老年疗养人员发生跌倒案例17起,发生率12.24‰;根因分析法实施以后(2016年3~11月),老年疗养人员发生跌倒案例5例,发生率为3.86‰。前后相比,跌倒率差异显著(P<0.05)。结论:将根因分析法应用到老年疗养人员防跌倒管理中,能根据主要原因制定更有针对性的管理措施,进而有效降低老年疗养人员的跌倒率,提高护理服务质量。 Objective: To explore the value of root cause analysis in strengthening the management of the fall of the elderly convalescent people. Methods: Root cause analysis was used to analyze and analyze the fall cases of the aged people in the nursing home in Wuyunshan, Hangzhou. The main causes were identified and targeted prevention and control measures were formulated. The fall rate of the old people For the evaluation of indicators, study the implementation of root cause analysis. Results: Before the implementation of the root cause analysis (March-November 2015), cases of falls occurred in 17 elderly aged people, the incidence rate was 12.24 ‰. After the root cause analysis was carried out (March-November 2016), elderly convalescents occurred Five cases of falling cases, the incidence was 3.86 ‰. The fall rate was significantly different between before and after treatment (P <0.05). Conclusion: Applying the root cause analysis method to the anti-fall management of elderly convalescent patients, we can make more targeted management measures according to the main reasons, so as to effectively reduce the fall rate of elderly convalescent persons and improve the quality of nursing services.