— 照護管理 · HARD · MCQ —
下列哪種狀況構成必須通報的「警示事件」（Sentinel Event）？
Which of the following occurrences constitutes a sentinel event that must be reported?
- AA client falls and requires a small bandage on their arm病人跌倒且手臂需要小繃帶
- BA nurse forgets to document a set of vital signs護理師忘記記錄一組生命徵象
- CA client undergoes an appendectomy on the wrong side✓ 正解病人在錯誤側進行闌尾切除術
- DThe wrong medication is given, but the client shows no reaction給錯藥物，但病人沒有反應
— Explanation · 中文詳解 —
警示事件（Sentinel Event）是指導致病人死亡或嚴重生理/心理傷害的非預期事件。這類事件必須經過根本原因分析（Root Cause Analysis, RCA），並通報醫療品質相關機構。手術部位錯誤（Wrong-site surgery）是公認的「永不發生事件（Never Event）」，絕對屬於警示事件。
A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, such as wrong-site surgery, which is classified as a 'never event.' Because these events represent severe failures in safety protocols, they require immediate reporting and a root cause analysis to prevent recurrence.
✦ 台美臨床差異
美國醫界對於「Never Event」有極嚴格的定義與通報機制，並由 Joint Commission (TJC) 監控。這些數據會影響醫院的評鑑與保險給付，因此對於醫療錯誤的處理與通報文化非常直接。