一位加護病房護理師發現給藥紀錄上的錯誤。護理師給了 50 mg 的 Metoprolol，而不是處方的 25 mg。病患心跳短暫降到 52 下，但現在穩定在 65 下，血壓 110/70 mmHg。在通知醫師後，護理師準備記錄。哪項記錄明確違反了關於醫療紀錄的風險管理標準？
An intensive care nurse discovers an error on a client's medication administration record. The nurse administered 50 mg of Metoprolol instead of the prescribed 25 mg. The client's heart rate briefly dropped to 52 bpm but is now stable at 65 bpm with a BP of 110/70 mmHg. After notifying the physician, the nurse prepares to document the incident. Which documentation explicitly violates risk management standards regarding medical records?
- A“0900: Client received 50 mg of Metoprolol by mistake instead of 25 mg. Incident report #1234 filed with risk management.”✓ 正解「0900：客戶因故誤服 50 mg Metoprolol，而非處方的 25 mg。已向風險管理部提交異常事件通報單 #1234。」
- B“0900: Metoprolol 50 mg administered PO. 0930: HR 52 bpm, BP 105/65, Dr. Smith notified.”「0900：Metoprolol 50 mg 口服給藥。0930：HR 52 bpm，BP 105/65，已通知 Smith 醫師。」
- C“0930: Monitored the client's vital signs every 15 minutes after administering 50 mg Metoprolol. No current signs of cardiopulmonary distress observed.”「0930：給予 50 mg Metoprolol 後，每 15 分鐘監測病人生命徵象。目前未觀察到心肺窘迫跡象。」
- D“1000: Client resting comfortably. Current vital signs BP 110/70, HR 65. The physician provided no new orders to intervene.”「1000：病人安靜休息。目前生命徵象 BP 110/70，HR 65。醫師未提供新的介入醫囑。」
本題測驗風險管理與醫療紀錄的鐵律 (Incident Reports / Legal Liability)。當發生給藥錯誤時，護理師的官方病歷應該只用來客觀地記錄：給了什麼藥、給了多少劑量、生命徵象反應，以及醫師被通知後的處置。絕佳做法是記錄純客觀事實。但是，風險管理的最高禁忌是：『絕不能將「已提交異常事件通報單 (Incident report filed)」寫入官方病歷』。異常事件報告是專屬機密文件，一旦在可被法院傳喚的病歷中提及它，律師便能強行調閱。因此選 A。
This question tests an iron rule of risk management and medical record documentation regarding incident reports and legal liability. When a medication error occurs, the official medical record should be used only to objectively document what medication was given, at what dose, the patient's vital sign response, and the provider's actions after being notified. The best practice is to document purely objective facts. However, the most absolute prohibition in risk management is: 'never document in the official medical record that an incident report has been filed.' Incident reports are confidential documents; once they are referenced in a record that can be subpoenaed, attorneys can compel disclosure. Therefore, option A is the correct answer.
醫療事故雙軌紀錄 (Dual tracking)。病歷寫客觀事實，內部通報寫檢討報告，絕不跨界提及。