— 照護管理 · MEDIUM · MCQ —
護理長正在評估病房安全性，下列哪項事件應視為「哨兵事件」（Sentinel Event）進行回報？
A nurse manager is evaluating the safety of a unit. Which incident should be reported as a sentinel event?
- AA lab report is delayed by 30 minutes檢驗報告延遲30分鐘
- BA nurse gives the wrong medication, resulting in permanent harm✓ 正解護理師給錯藥物，導致永久性傷害
- CA client complains about the cold room temperature病人抱怨房間溫度過冷
- DA client falls out of bed but suffers no injury病人從床上跌落但未受傷
— Explanation · 中文詳解 —
哨兵事件是指導致病人死亡、永久性傷害或嚴重暫時性傷害的意外事件。給錯藥導致永久性損傷符合此定義。D 選項為「差錯（Near miss）或輕微傷害」，雖需檢討但未必達哨兵等級；A、C 為一般運作問題或客訴，不涉及病人生命安全。
A sentinel event is an unexpected occurrence that results in death, permanent harm, or serious temporary harm. A medication error resulting in permanent harm meets this definition. Option D represents a near miss or minor injury – though it warrants review, it does not necessarily reach sentinel level; A and C involve operational issues or complaints that do not threaten patient safety.
✦ 台美臨床差異
美國 JCAHO 對哨兵事件有明確統計與義務回報規範；台灣醫院多採病人安全通報系統，但對定義的嚴格程度因醫院而異。