— 照護管理 · MEDIUM · SATA —
護理師發現給藥錯誤，應優先採取哪些措施？（選所有適合的）
A nurse identifies a medication error. Which actions should the nurse prioritize? (Select all that apply.)
- AAssess the client for any adverse effects✓ 正解評估病人是否有不良反應
- BNotify the healthcare provider immediately✓ 正解立即通知醫療保健提供者
- CDocument the error in the client's medical record✓ 正解在病人的病歷中記錄錯誤
- DComplete an incident report for the facility✓ 正解完成機構的意外報告
- EPlace the incident report in the patient chart將意外報告放入病患病歷中
— Explanation · 中文詳解 —
給藥錯誤後，優先順序為：1. 評估病人狀況（安全性第一）；2. 通知醫師（醫療補救）；3. 記錄事件（病歷記載真實發生的事）；4. 填寫意外報告（院方品質改善）。絕對不可將意外報告放入病歷中，因報告屬內部品質監控文件，而非醫療紀錄。
After a medication error, the priority sequence is: 1) assess the client's condition (safety first); 2) notify the healthcare provider (medical mitigation); 3) document the event in the medical record (factual documentation of what actually occurred); and 4) complete an incident report (for institutional quality improvement). The incident report must never be placed in the chart, because it is an internal quality-monitoring document and not part of the medical record.
✦ 台美臨床差異
美國採取不究責（No-blame）文化，鼓勵通報；台灣醫療體系正逐漸向此方向改革。