— 照護管理 · HARD · SATA —
下列哪些屬於品質管理標準中必須通報的「哨兵事件」（sentinel events）？（選所有適合的）
Which of the following are examples of 'sentinel events' that must be reported according to quality management standards? (Select all that apply.)
- APatient fall resulting in a minor bruise導致輕微瘀傷的病人跌倒
- BWrong-site surgical procedure✓ 正解手術部位錯誤
- CUnexpected death of a patient✓ 正解病人非預期死亡
- DMedication error requiring increased monitoring需要增加監測的藥物錯誤
- EUnintended retention of a foreign object after surgery✓ 正解手術後意外遺留異物
— Explanation · 中文詳解 —
哨兵事件定義為導致嚴重心理或生理傷害，甚至是死亡的非預期事件。錯誤部位手術、非預期死亡與手術後遺留異物均符合此定義。選項 A 與 D 屬於事件（incident），雖需記錄，但不一定達到哨兵事件的嚴重程度。
Sentinel events are unexpected occurrences resulting in serious physical or psychological injury or death. Wrong-site surgery, unexpected death, and retained foreign objects after surgery all meet this definition. Options A and D are incidents that must be documented but do not necessarily rise to sentinel event severity.
✦ 台美臨床差異
美國 JCAHO 對哨兵事件有詳細定義與通報機制；台灣衛福部亦有病人安全通報系統（TPR）。