— 安全與感染控制 · MEDIUM · MCQ —
下列何者屬於需要通報的不良事件（Adverse Event）？
Which of the following is an example of an adverse event that should be reported?
- AA client complains about the room temperature一位客戶抱怨房間溫度
- BA nurse was late for her shift一位護理師遲到上班
- CA visitor brought non-compliant food一位訪客帶入不符合規定的食物
- DA medication error occurred but did not harm the client✓ 正解發生藥物錯誤但未對客戶造成傷害
— Explanation · 中文詳解 —
不良事件（Adverse Event）通報是醫療品質改善的重要機制。即使錯誤未造成實質傷害，仍需進行「未遂事件（Near Miss）」或不良事件通報，以便透過系統分析（Root Cause Analysis, RCA）找出流程漏洞。隱匿錯誤會阻礙系統改進，增加未來發生嚴重傷害的風險。護理師應具備「不責備文化（Just Culture）」的觀念，主動參與通報。
Reporting near misses, such as medication errors that did not cause harm, is essential for identifying system vulnerabilities through root cause analysis. This practice supports a just culture focused on quality improvement rather than blame, helping to prevent future serious adverse events.
✦ 台美臨床差異
美國醫療體系非常強調「不責備文化（Just Culture）」，鼓勵護理師主動回報錯誤。台灣部分醫療機構仍存在責備文化，導致員工傾向隱匿錯誤。在 NCLEX 考試中，永遠選擇「通報以利系統改善」的選項。