— 照護管理 · HARD · MCQ —
護理師正在督導新進護理師，若新進護理師執行下列哪項動作，需要介入糾正？
A nurse is supervising a newly licensed nurse. The nurse intervenes if the new nurse performs which action?
- ADocumenting a medication error in the client's medical record✓ 正解在病人的病歷中記錄藥物錯誤
- BUsing two patient identifiers before performing a blood transfusion在執行輸血前使用兩項病人識別資訊
- CAsking the client to state their name and birth date before medication administration在給藥前請病人自述姓名和出生日期
- DVerifying the client's allergy status before ordering a meal tray在訂購餐盤前驗證病人的過敏狀態
— Explanation · 中文詳解 —
醫療錯誤紀錄（Incident Report / Occurrence Report）的目的是品質改善，而非懲罰。此文件屬於機構內部文件，嚴禁放入病人的正式病歷（Medical Record）中。若將錯誤紀錄寫在病歷，會成為法律訴訟中的不利證據，且違反了品質管理的保密原則。護理師應僅在病歷中記錄「事實」（如：病人給藥後狀況、醫師評估與處理），而非「發生了錯誤」。
Nursing supervision should intervene if a new nurse documents a medication error in the client's medical record, as incident reports are internal quality improvement tools and must not become part of the legal medical record. Patient identification using two identifiers and verifying allergies are correct safety practices.
✦ 台美臨床差異
台灣醫院有時會將錯誤紀錄與病歷混淆，但在美國，Incident Report 與 Medical Record 的嚴格分離是律師與風險管理師極度強調的重點，這是為了保護醫院與護理人員免於在法律訴訟中產生不利的書面證據。