目的通过对患者跌倒事件的原因分析,提出护理安全管理对策,降低跌倒的发生率,保证患者安全。方法对我院住院患者发生的35例跌倒事件进行回顾性分析,采用根本原因分析法进行原因分析。结果造成患者跌倒的原因有患者自身的因素、医护人员的因素、陪护及家属的因素、管理因素、环境因素,设备因素。60岁以上跌倒患者占91.4%;原发疾病高血压、冠心病、卒中后遗症占40%;有陪护占60%。结论要在安全管理制度上层层把关,关口前移,同时加强护理人员的培训教育,重视环境、设备的安全、加强对患者及家属、陪护的安全宣教,提高对高危人群危险的认识和处理能力,是防范跌倒的关键。 Objective To analyze the causes of falls in patients and to propose nursing safety management strategies to reduce the incidence of falls and ensure patient safety. Methods A retrospective analysis of 35 cases of falls in hospitalized patients in our hospital was carried out, and the causes were analyzed by the method of root cause analysis. As a result, patients fell into the hospital due to their own factors, medical and nursing staff, accompanying and family members, management, environmental and equipment factors. Patients over the age of 60 fall accounted for 91.4%; primary disease, hypertension, coronary heart disease, stroke sequelae accounted for 40%; accompanied by 60%. Conclusion At the upper levels of the safety management system, we need to improve the training and education of nurses, attach importance to the safety of the environment and equipment, and enhance the missionary safety education for patients, their families and their escorts, and raise the awareness and handling capacity for the risks of high-risk groups , Is the key to guard against falling.