— 照護管理 · HARD · SATA —
哪些屬於護理管理必須致力杜絕的「絕對不發生事件」（Never Events）？（選所有適合的）
Which of the following are examples of 'Never Events' that nursing management must work to eliminate? (Select all that apply.)
- APatient developing a stage 3 pressure ulcer during hospitalization✓ 正解住院期間發展出第三期壓瘡
- BPatient receiving the wrong blood type during transfusion✓ 正解輸血時接受不合血型
- CPatient experiencing a minor rash from a new soap因新肥皂產生輕微皮疹
- DPatient undergoing surgery on the incorrect body part✓ 正解在錯誤的身體部位進行手術
- EPatient experiencing an expected side effect of a medication經歷藥物的預期副作用
— Explanation · 中文詳解 —
Never Events 定義為嚴重、可預防且損害病人安全的醫療疏失。褥瘡（A）、輸錯血（B）與開錯部位手術（D）均被視為絕對不應發生的錯誤，醫療保險通常會因此拒付。C 與 E 為醫療過程中可能發生的常見不良反應，不屬此定義。
Never Events are defined as serious, preventable medical errors that compromise client safety. Pressure ulcers (A), administration of incompatible blood products (B), and wrong-site surgery (D) are all considered errors that should never occur, and insurance typically refuses reimbursement for them. Options C and E represent common adverse reactions that may occur during the course of care and do not fit this definition.
✦ 台美臨床差異
美國 CMS 對 Never Events 有拒付條款；台灣健保亦有品質指標管理，但懲罰機制較不同。