— 照護管理 · HARD · SATA —
哪些行動有助於在醫療機構中建立「不責難文化」（Just Culture）？（選所有適合的）
Which of the following actions assist in creating a Just Culture in a healthcare facility? (Select all that apply.)
- AEncouraging non-punitive reporting of errors✓ 正解鼓勵非懲罰性的錯誤通報
- BFocusing on systems improvement rather than individual blame✓ 正解著重於系統改善而非個人責備
- CPublicly shaming individuals who make errors公開羞辱犯錯的個人
- DAnalyzing near-miss events for learning opportunities✓ 正解分析險失事件以作為學習機會
- EIgnoring small errors to maintain morale忽略小錯誤以維持士氣
— Explanation · 中文詳解 —
「不責難文化」（Just Culture）的核心在於區分「人為失誤」（Human error）、「風險行為」（At-risk behavior）與「魯莽行為」（Reckless behavior）。醫療機構應致力於改善系統漏洞，讓錯誤在發生前被攔截，而非透過懲罰個人來隱蔽錯誤。這種文化能鼓勵員工主動通報險失事件（Near-miss），從而提升整體醫療系統的安全性。
The core of a Just Culture is distinguishing among human error, at-risk behavior, and reckless behavior. Healthcare organizations should focus on improving system vulnerabilities so that errors are intercepted before they reach the patient, rather than concealing errors through individual punishment. This culture encourages staff to proactively report near-miss events, thereby improving the overall safety of the healthcare system.