在醫療照護中，下列哪項被視為「哨兵事件」（Sentinel Event）？
Which of the following is considered a 'sentinel event' in healthcare?
- AA nurse taking a break護理師休息
- BWrong-site surgery✓ 正解錯位手術
- CA minor medication delay輕微用藥延遲
- DA patient falling while being ambulated病人步行時跌倒
「哨兵事件」（Sentinel Event）根據聯合委員會（The Joint Commission, TJC）定義，是指非預期性的死亡或嚴重身體/心理傷害事件。這類事件需立即調查並採取根本原因分析（Root Cause Analysis, RCA），以防止再發生。錯位手術直接導致病人受到嚴重且永久的傷害，符合定義。
A sentinel event is defined by The Joint Commission as an unexpected occurrence involving death or serious physical or psychological injury. Wrong-site surgery is a classic example because it results in severe, permanent harm and requires immediate investigation and root cause analysis. Other options, such as taking breaks or minor delays, do not meet the criteria for serious, irreversible harm associated with sentinel events.
美國醫院對於哨兵事件的定義與通報流程由 TJC 嚴格規範，且強制要求進行 RCA。台灣醫院評鑑與病人安全通報系統雖參照此架構，但在文化上，美國更強調「不究責文化」（Just Culture），鼓勵主動報告以改善系統而非懲罰個人。