— 安全與感染控制 · HARD · MCQ —
下列哪種情境符合安全標準中的「近乎錯誤（Near Miss）」？
Which of the following scenarios describes a 'near miss' according to safety standards?
- AA client receives the wrong medication but shows no symptoms.病人接受了錯誤的藥物但未出現症狀。
- BA nurse documents medication that was never administered.護理師記錄了從未給藥的藥物。
- CA nurse notices a wrong dose ordered and stops it before administration.✓ 正解護理師注意到開立的劑量錯誤，並在給藥前予以制止。
- DA client falls out of bed because the side rails were left down.由於床欄放下，病人從床上摔落。
— Explanation · 中文詳解 —
近乎錯誤（Near Miss）是指錯誤已經發生，但在藥物或醫療處置進入病人體內前，被及時發現並攔截，未造成病人傷害。A 選項屬於給藥錯誤，即使未產生症狀也非近乎錯誤；D 選項為不良事件；B 選項為醫療紀錄錯誤，不屬於近乎錯誤範疇。
A near miss is defined as an error that occurs but is intercepted before it reaches the patient, thereby preventing any harm. In this scenario, the nurse identified the wrong dose and stopped it prior to administration, fitting the criteria for a near miss rather than an actual medication error or adverse event.
✦ 台美臨床差異
美國醫院採取不責備文化（Just Culture）鼓勵通報近乎錯誤，台灣醫院亦推行病人安全通報系統（TPR）。