— 安全與感染控制 · HARD · SATA —
下列哪些情況需要護理師填寫異常事件報告（Incident Report）？（選所有適合的）
Which of the following situations requires the nurse to file an incident report? (Select all that apply.)
- AA client falls while getting out of bed, sustaining a minor bruise✓ 正解病人在下床時跌倒，造成輕微瘀傷
- BA medication dose was administered 30 minutes later than scheduled✓ 正解藥物劑量比預定時間晚給予 30 分鐘
- CA nurse discovers a medication error before it is administered✓ 正解護理師在給藥前發現藥物錯誤
- DA visitor slips on a wet floor in the hallway✓ 正解訪客在走廊濕滑地板上滑倒
- EA client experiences a sudden decline in blood pressure病人血壓突然下降
— Explanation · 中文詳解 —
異常事件報告的目的是品質改善而非懲罰。凡是異常發生（跌倒、給藥延誤、給藥錯誤即使未發生傷害、訪客受傷）皆需紀錄。E 選項屬於病人病情惡化，屬於常規醫療護理範疇，除非涉及處理疏失，否則不屬於異常事件報告。
The purpose of an incident report is quality improvement rather than punishment. Any abnormal occurrence (a fall, a medication delay, a medication error even without harm, or a visitor injury) must be documented. Option E represents clinical deterioration in the client and falls within the scope of routine medical and nursing care; unless it involves a management error, it is not the subject of an incident report.
✦ 台美臨床差異
美國醫院內部異常事件系統（如 Sentinel Event reporting）非常成熟，且鼓勵不懲罰文化；台灣醫院亦有異常通報機制，但仍有部分護理人員擔心受罰而通報意願較低。