— 照護管理 · HARD · SATA —
哪些情況屬於需要進行根本原因分析（RCA）的重大事件（Sentinel Event）？（選所有適合的）
Which of the following are examples of sentinel events that require a root cause analysis (RCA)? (Select all that apply.)
- APatient death related to a medication administration error✓ 正解與藥物給藥錯誤相關的病人死亡
- BA minor fall resulting in a small bruise導致小瘀傷的輕微跌倒
- CWrong-site surgical procedure✓ 正解錯誤部位的外科手術
- DSuicide of a patient while in a 24-hour care facility✓ 正解病人在24小時照護設施中自殺
- EA patient reporting long wait times for a sandwich病人報告三明治等待時間過長
— Explanation · 中文詳解 —
重大事件（Sentinel Event）指導致死亡或永久性身體/心理功能喪失的非預期事件。用藥致死、錯誤部位手術、病患於住院期間自殺，皆屬於必須進行 RCA 的重大項目。輕微跌倒或服務滿意度問題通常歸類於一般異常事件報告。
A sentinel event is an unexpected occurrence resulting in death or permanent physical or psychological loss of function. Medication-related death, wrong-site surgery, and inpatient suicide are major events requiring root cause analysis (RCA). Minor falls and service-satisfaction problems are typically categorized as ordinary incident reports.
✦ 台美臨床差異
美國 Joint Commission 嚴格定義 Sentinel Event；台灣醫院評鑑中亦有類似的病安通報與 RCA 程序，定義高度一致。