護理長發現護理師給藥前未核對病人身份，首要處置為何？
A charge nurse observes a staff nurse failing to verify client identity before medication administration. What is the priority action?
- ADocument the incident in the client’s medical record將事件記錄於病歷中
- BIntervene immediately to prevent a medication error✓ 正解立即介入以防止用藥錯誤
- CReport the nurse to the nursing board immediately立即向護理師公會舉報該護理師
- DWait until the end of the shift to counsel the nurse等到班次結束再輔導該護理師
在護理實務中，病人安全（Patient Safety）永遠是最高優先級。當觀察到未核對身分即給藥的行為，護理師必須立即介入以中斷錯誤鏈條，防止藥物錯誤（Medication Error）發生。這屬於「不安全行為」的即時處置。事後再進行教育、輔導或提報 incident report 是後續程序，不能因為要走行政流程而延誤阻止傷害的機會。
Client safety is the highest priority; therefore, the charge nurse must intervene immediately to stop the medication error when a staff nurse fails to verify identity. Preventing harm takes precedence over documentation or disciplinary reporting, which should occur after the immediate danger is resolved. Delaying intervention to wait for counseling or filing reports puts the client at unnecessary risk.
美國醫院對病人安全採取「不責難文化」（Just Culture），鼓勵及時糾正與通報，重點在於流程改善而非單純懲罰個人。