— 照護管理 · HARD · MCQ —
下列哪項事件構成必須報告給風險管理部門的「哨兵事件（Sentinel Event）」？
Which of the following incidents constitutes a sentinel event that must be reported to risk management?
- AA nurse discovers a minor medication error that resulted in no harm to the client護理師發現一處未對病人造成傷害的輕微用藥錯誤
- BA client experiences an allergic reaction to a medication that was previously documented病人對先前已記錄在案的藥物產生過敏反應
- CA client is found on the floor without injury after a fall while attempting to walk病人在嘗試行走時跌倒，但被發現時未受傷
- DA surgery is performed on the wrong body part of the client✓ 正解對病人的錯誤身體部位進行了手術
— Explanation · 中文詳解 —
哨兵事件是指導致病患死亡、永久傷害或嚴重暫時性傷害的非預期事件。錯誤手術部位（Wrong-site surgery）是 Joint Commission 定義的絕對哨兵事件。B 屬於給藥疏失但未說明嚴重度；B 跌倒若無傷害較輕；D 為近失誤（Near-miss），雖需通報但未達哨兵層級。
A sentinel event is an unexpected occurrence that causes patient death, permanent harm, or severe temporary harm. Wrong-site surgery is an absolute sentinel event as defined by the Joint Commission. Option B is a medication error of unspecified severity; option C, a fall without injury, is less serious; option A is a near-miss event that must be reported but does not meet the threshold of a sentinel event.
✦ 台美臨床差異
美國透過 TJC 嚴格管控哨兵事件定義；台灣醫院評鑑亦參考此機制，但通報文化仍常受罰則影響而傾向淡化。