— 照護管理 · HARD · MCQ —
護理長正在執行減少給藥錯誤的新政策。哪一項策略對於長期改善最有效？
A nurse manager is implementing a new policy to reduce medication errors. Which step is most effective for long-term improvement?
- AImplementing a checklist for all medication administrations.實施所有給藥程序的查檢表。
- BDisciplinary action for the nurse involved in the error.對涉及錯誤的護理師採取紀律處分。
- CDeveloping a culture of safety that encourages reporting of near misses.✓ 正解培養鼓勵通報未遂事件的安全文化。
- DMandating additional training for all staff members.強制要求所有員工接受額外訓練。
— Explanation · 中文詳解 —
現代醫療品質管理強調「非懲罰性安全文化（Just Culture）」。鼓勵報告「未遂事件（near misses）」能幫助系統識別潛在風險並進行根本原因分析（RCA），比單純的處罰更能從根本上預防錯誤重演。
A 'Just Culture' approach to medication safety promotes non-punitive reporting of errors and near misses so the organization can perform root-cause analysis and address systemic vulnerabilities. Punishing individuals discourages reporting and hides hazards. Training and checklists are useful tools, but they depend on a safety culture to be sustained.
✦ 台美臨床差異
美國導入嚴謹的 Just Culture；台灣醫療環境受限於傳統文化，對錯誤回報仍存有心理障礙。