下列何者屬於需要調查的「哨兵事件」（Sentinel Event）？
Which of the following is an example of a sentinel event requiring investigation?
- AA nurse taking a 5-minute break護理師休息 5 分鐘
- BThe wrong medication being administered to a client✓ 正解給病人錯誤的藥物
- CA client slipping in the hall but not getting injured病人在走廊滑倒但未受傷
- DA client complaining about cold food病人抱怨食物太冷
哨兵事件（Sentinel Event）指在醫療機構中發生的、非預期的、導致病人死亡、永久性傷害或嚴重暫時性傷害的事件。這類事件要求醫療機構立即進行根本原因分析（Root Cause Analysis, RCA），以探討系統性缺失並防止再發生。錯誤給藥若導致嚴重後果，無疑屬於此類範疇，必須嚴肅處理。
A sentinel event refers to an unexpected occurrence in a healthcare facility that results in patient death, permanent harm, or severe temporary harm. Such events require the healthcare facility to immediately conduct a root cause analysis (RCA) to investigate systemic deficiencies and prevent recurrence. Wrong medication administration, if it results in serious consequences, unquestionably falls into this category and must be addressed seriously.
美國醫院對哨兵事件有極嚴格的報告機制，通常由聯合委員會（The Joint Commission）強制規範，並要求強制性進行 RCA；台灣雖有通報系統，但在定義的強制性與 RCA 的執行深度上，美國的規範更具法律效力。