— 照護管理 · MEDIUM · SATA —
護理長欲推動安全變革，哪些策略能促進『公正文化』（Just Culture）？（選所有適合的）
A nurse manager is implementing a safety change. Which strategies promote a 'Just Culture'? (Select all that apply.)
- AEncouraging non-punitive reporting of errors✓ 正解鼓勵非懲罰性的錯誤通報
- BFocusing on learning from mistakes rather than individual blame✓ 正解著重從錯誤中學習而非歸咎個人
- CPublicly shaming employees who make errors公開羞辱犯錯的員工
- DAnalyzing system processes for root causes✓ 正解分析系統流程以找出根本原因
- EProviding feedback to the staff on system improvements✓ 正解向員工提供關於系統改善的回饋
— Explanation · 中文詳解 —
公正文化的核心在於：區分『人為失誤』（應鼓勵通報與學習）、『危險行為』（應管理）與『惡意違規』（應懲戒）。推動重點在於非懲罰性通報、從錯誤中學習、進行 RCA 分析、並對員工回饋系統改善成果。公開羞辱是極力避免的行為。
A Just Culture distinguishes between human error, risky behavior, and reckless conduct, focusing on system improvement rather than individual blame. Strategies include encouraging non-punitive error reporting, conducting root cause analyses, and providing staff feedback on system changes. Public shaming is counterproductive and undermines trust and safety.
✦ 台美臨床差異
台灣醫院評鑑已納入公正文化要求，但臨床現場仍需打破『犯錯即懲處』的舊有心態。