— 安全與感染控制 · HARD · SATA —
下列何者屬於醫療機構中的「從不發生事件」(Never Events)？（選所有適合的）
Which of the following represents a 'Never Event' in a healthcare setting? (Select all that apply.)
- ASurgery performed on the wrong body part✓ 正解在錯誤的身體部位進行手術
- BPatient fall resulting in a minor bruise病人跌倒導致輕微瘀傷
- CForeign object left in a patient after surgery✓ 正解手術後體內殘留異物
- DDischarge of an infant to the wrong person✓ 正解將嬰兒交付給錯誤的人
- EStage 3 pressure injury acquired after admission✓ 正解入院後發展成第3期壓瘡
— Explanation · 中文詳解 —
Never Events 是嚴重、可預防且不應發生的醫療疏失。包含錯部位手術、手術留置異物、嬰兒交付錯誤對象以及院內獲得的第 3-4 級壓瘡。輕微跌倒通常被視為不良事件(Adverse Event)，但不屬於 Never Event 定義範圍。
Never Events are serious, preventable medical errors that should never occur. They include wrong-site surgery, retention of foreign objects after surgery, discharge of an infant to the wrong person, and hospital-acquired Stage 3–4 pressure injuries. A minor fall is typically classified as an adverse event but does not fall within the formal definition of a Never Event.
✦ 台美臨床差異
美國醫策會 (NQF) 對 Never Event 定義明確，台灣則稱為「異常事件」，雖然分類相似，但罰則與通報機制略有不同。