— 照護管理 · HARD · MCQ —
護理師因系統錯誤發現病人潛在受害風險，通報的目標為何？
A nurse identifies a potential risk of harm to a client due to a system error. What is the goal of reporting this?
- ATo improve safety processes and prevent future harm✓ 正解改善安全流程並預防未來傷害
- BTo show the staff's incompetence顯示員工能力不足
- CTo keep the incident secret from hospital administration向醫院行政部門保密事件
- DTo punish the individual who designed the system懲罰設計該系統的人員
— Explanation · 中文詳解 —
報告系統性漏洞（System Error）的目標在於『品質改善』（Quality Improvement）。透過根本原因分析（RCA），識別系統缺陷並優化流程，是現代醫療安全的核心。這並非為了懲罰個人，而是為了預防未來的傷害再次發生，這也是 Just Culture 的精隨。
The goal of reporting a system error is 'quality improvement.' Through root cause analysis (RCA), system defects are identified and processes are optimized; this is central to modern healthcare safety. The purpose is not to punish individuals, but to prevent future harm from recurring, which embodies the essence of Just Culture.
✦ 台美臨床差異
美國醫院廣泛運用 RCA（Root Cause Analysis）；台灣目前在醫策會引導下，亦逐步強化 RCA 在病人安全事件中的應用。