下列哪些護理介入措施有助於預防醫院中的「警示事件」（Sentinel Events）？（選所有適合的）
Which of the following nursing interventions help prevent sentinel events in a hospital setting? (Select all that apply.)
- AUsing two patient identifiers before any procedure✓ 正解在任何程序前使用兩項病人識別資料
- BEncouraging a culture of blame to identify mistakes鼓勵建立指責文化以找出錯誤
- CConducting time-outs before invasive procedures✓ 正解在侵入性程序前執行暫停確認（time-out）
- DVerifying medication orders via telephone with read-back✓ 正解透過電話並回誦方式確認藥物醫囑
- EPromoting effective hand-off communication using SBAR✓ 正解使用 SBAR 促進有效的交班溝通
警示事件（Sentinel Events）是指醫院內發生導致病人死亡、永久性傷害或嚴重暫時性傷害的非預期事件。預防的核心在於建立「安全文化」（Safety Culture），透過系統性的防錯機制來阻斷錯誤鏈。正確選項均為聯合委員會（The Joint Commission, TJC）針對病人安全目標（National Patient Safety Goals）所要求的標準實務。護理師應將這些措施內化為臨床常規，而非僅視為行政要求，以提升病人照護安全。
Sentinel events refer to unanticipated events in the hospital that result in patient death, permanent harm, or severe temporary harm. The core of prevention lies in establishing a safety culture and interrupting error chains through systematic error-prevention mechanisms. The correct options are all standard practices required by The Joint Commission (TJC) as part of the National Patient Safety Goals. Nurses should internalize these measures as routine clinical practice rather than treating them merely as administrative requirements, in order to enhance patient care safety.
台灣醫院評鑑與美國TJC標準高度接軌，但美國對於「Time-out」的執行要求更為嚴格，通常需暫停所有工作、全員參與並確認程序正確，且在臨床紀錄中會強制要求標註已完成 Time-out。