— 照護管理 · MEDIUM · MCQ —
護理師應將下列哪項紀錄為「異常事件」報告？
Which of the following findings should the nurse document as an 'incident' or 'occurrence'?
- AA client falling out of bed while the rails were down✓ 正解床欄放下時病人從床上摔落
- BA family member asking about the client's prognosis家屬詢問病人的預後
- CA client expressing dissatisfaction with food quality病人對食物品質表示不滿
- DA client refusing a scheduled medication病人拒絕按時服藥
— Explanation · 中文詳解 —
異常事件報告（Incident Report）用於紀錄非預期的意外事件，旨在進行品質改善（Root Cause Analysis）。病人跌倒（A）屬於對病人安全造成威脅的異常事件。其他項目屬於照護過程中的溝通或選擇，不需填寫事故報告。
An incident report is required for unexpected events that pose a risk to patient safety, such as a client falling out of bed. This documentation facilitates root cause analysis and quality improvement initiatives. Routine communications, food complaints, or medication refusals are documented in the medical record but do not constitute reportable incidents.
✦ 台美臨床差異
美國異常事件報告（Occurrence Report）絕對不放入醫療紀錄（Chart）；台灣部分醫院習慣寫在護理紀錄中，需注意法律風險。