一位因肺炎住院的76歲男性在凌晨三點被發現跌坐在床邊地板上。他表示：「我想用廁所但腿軟了。」評估顯示血壓 138/85 mmHg，心跳 82 次/分，且無明顯受傷。護理師已完成全面評估、協助他回床並通知醫師。在填寫異常事件通報單（Incident report）時，護理師何項處置是正確的？
A 76-year-old male admitted for pneumonia is found sitting on the floor beside his bed at 0300. He states, "I wanted to use the toilet but my legs gave out." Assessment reveals BP 138/85 mmHg, HR 82 bpm, and no obvious injuries. The nurse completes a thorough assessment, assists him back to bed, and notifies the provider. When completing the occurrence (incident) report, which action by the nurse is correct?
- AObjectively describe the facts of the event and the patient's exact words within the report, forwarding it to risk management.✓ 正解客觀描述事件事實及患者的原話，並將報告提交給風險管理部
- BState in the report that the nursing staff was at fault due to insufficient monitoring leading to the fall.在報告中指出護理人員因監測不足導致跌倒而應負起責任
- CPlace a copy of the completed occurrence report into the patient's medical record for transparency.將填好的異常事件報告副本放入患者病歷中以示透明
- DDocument in the patient's nursing notes that "an occurrence report was filed for a fall event."在護理紀錄中記載「已針對跌倒事件填寫異常事件報告」
本題測試異常事件通報（Incident / Occurrence Report）的正確法定與管理實務。異常通報屬於醫院內部的風險管理工具，旨在分析系統錯誤並改進品質，並不屬於病患的正式醫療紀錄（Medical Record）。若將通報單放進病歷（排除C），或在護理紀錄中提及「已填寫異常通報」（排除D），在美國法律上，該通報單就失去保護傘，可被原告律師透過傳票合法調閱作為醫療疏失的定罪證據。在填寫內容方面，護理師只應記錄客觀發現與家屬/病患的原話陳述（選項A正確），絕對不可在通報單或病歷中夾帶主觀猜測、承認過失（指責自己或同事失職）（排除B）。
Strict hand hygiene is the most effective method to prevent infection transmission. Airborne precautions require negative-pressure rooms, and limiting staff entry reduces exposure risk. Masks are not needed for all contacts, and sterile gloves are unnecessary for routine assessments.
台灣醫院近年推行 TPR (台灣病人安全通報系統)，同樣強調「不寫入病歷、不咎責」文化，這點與美國NCLEX標準幾乎完全同步。但在台灣臨床文化偶爾仍可見護理師為自保而在護理紀錄上詳述跌倒過失，這在美國實務中是被嚴格禁止的。