加護病房護理師發現給藥錯誤，錯誤輸入了 0.45% 氯化鈉而不是 0.9% 氯化鈉。目前病患穩定但需填寫異常事件通報單。根據風險管理協議，什麼資料嚴格禁止被記錄在官方病歷上？
An intensive care nurse discovers an error on a client's MAR. The nurse infused a full liter of 0.45% NaCl instead of the prescribed 0.9% NaCl. The client is currently stable but requires an incident report. Which specific data must be excluded strictly from the client's official medical chart according to risk management protocols?
- AThe specific name and title of the physician covering the unit who was notified regarding the event.關於該事件被通知之負責該單位的醫師姓名和職稱。
- BThe exact volume and solution type of the incorrect intravenous fluid actually administered to the client.實際上給予客戶的錯誤靜脈輸液之確切體積和溶液類型。
- CThe precise hourly vital signs obtained strictly after the intravenous medication error occurred.嚴格在靜脈藥物錯誤發生後獲得的精確每小時生命徵象。
- DA definitive reference stating that an institutional incident report was formally completed and filed.✓ 正解明確指出已正式完成並提交機構異常事件通報單的參考資料。
本題再次強化異常通報單保護傘 (Incident Report confidentiality)。在美國法律下，通報單 (Incident report) 是醫院品管部的『內部機密文件』。若在法定病歷中寫下『已完成通報單』，提告律師就能依法調閱這份原本受保護的檢討報告，把醫院的內部檢討變成呈堂證供。因此，病歷只能寫客觀事實 (選項 B、C、A 皆須紀錄)，絕對不能提及通報單。
An incident report is a confidential internal document used for quality improvement and should never be referenced in the client's permanent medical record. While factual details of the error and subsequent monitoring must be documented, mentioning the existence of the incident report can waive its legal protection and expose it during litigation.
Incident report 絕不能寫進病歷 (Medical record) 中，這是國考每年必考的法律鐵律。