加護病房護理師發現給藥錯誤。她給了 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。通知醫師後，護理師填寫了異常事件通報單。為何在病患的官方醫療紀錄中『嚴格禁止』提及這份異常事件通報單？
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 files an incident report. Why is it strictly forbidden to mention the incident report within the client's official medical record?
- AMentioning the incident report in the medical chart exposes a confidential internal document to legal subpoenas.✓ 正解在病歷中提及異常事件通報單，會使該機密內部文件暴露於法律傳票之下。
- BAn incident report is only necessary if the client actually suffered permanent physical harm.僅當病患實際上遭受永久性身體傷害時，才需要填寫異常事件通報單。
- CReferencing the incident report duplicates the paperwork process unnecessarily.參考異常事件通報單會不必要地重複文書處理程序。
- DThe physician must be the only person legally allowed to mention incident reports in the chart.只有醫師在法律上被允許在病歷中提及異常事件通報單。
本題測驗醫療錯誤與風險管理 (Incident Reports / Risk Management)。醫院的異常事件通報單 (Incident Report/Occurrence Report) 是給內部『品質監控與風險管理部門 (Quality Improvement)』用來檢討系統流程的專屬『機密文件』。一旦護理師在公開、屬於病人的法定病歷 (Medical Record) 裡面寫下「已填寫異常報告單」，這份內部機密文件的保護傘就會立刻破滅。在醫療糾紛官司中，律師就能透過這句話，向法院申請強制傳喚這份原本保密的檢討報告，將其變為不利於醫院的呈堂證供。因此，病歷只能寫客觀事實，絕不能提及內部通報單。
This question tests medication error and risk management (Incident Reports / Risk Management). The hospital's incident/occurrence report is a confidential internal document used exclusively by the Quality Improvement and Risk Management departments to review systemic processes. Once the nurse writes 'incident report filed' in the client's public legal medical record, the protective umbrella surrounding the internal confidential document is immediately removed. In medical malpractice litigation, an attorney can use such a notation to subpoena the originally confidential review report, turning it into damaging evidence against the hospital. Therefore, the medical record should contain only objective facts and must never reference the internal incident report.
台美皆有的雙軌制鐵律：病歷只寫客觀發生了什麼(給錯藥/生命徵象)，內部通報用來檢討為何做錯(太累/標籤太像)。兩者如同水火不可在病歷上互相提及。