— 降低風險 · HARD · SATA —
下列哪些項目屬於醫院必須致力於預防的「不應發生事件」（Never Events）？（選所有適合的）
Which of the following are considered 'Never Events' that nurses and institutions must prevent? (Select all that apply.)
- APatient falls resulting in serious injury✓ 正解導致嚴重傷害的病人跌倒
- BStage 3 or 4 pressure injuries acquired in the hospital✓ 正解在醫院內發生的第三或第四期壓瘡
- CSurgery on the wrong body part✓ 正解錯誤部位的手術
- DDevelopment of a surgical site infection手術部位感染的發生
- ERetained foreign object in a patient after surgery✓ 正解術後病人體內遺留異物
— Explanation · 中文詳解 —
「Never Events」是指醫療照護中絕對不應發生、且具嚴重後果的錯誤。包括嚴重跌倒、院內獲得性壓力性損傷（Stage 3/4）、錯誤部位手術、以及術後留置異物。手術部位感染雖然嚴重，但有時受病人本身因素影響，不完全歸類為「Never Events」。
Never Events refer to errors in health care that should absolutely never occur and have serious consequences. They include serious falls, hospital-acquired pressure injuries (Stage 3/4), wrong-site surgery, and retained foreign bodies after surgery. Although surgical site infections are serious, they are sometimes influenced by patient-specific factors and are not entirely classified as Never Events.
✦ 台美臨床差異
美國有嚴格的 Medicare/Medicaid 不給付「Never Events」政策，台灣則在醫療品質指標中進行監控與檢討。