護理師參與用藥錯誤後的根本原因分析（RCA），其主要目標為何？
The nurse is participating in a root cause analysis (RCA) following a medication error. What is the main goal of the RCA?
- ATo satisfy legal requirements for hospital accreditation滿足醫院認證的法律要求
- BTo identify systemic factors that contributed to the error✓ 正解識別導致錯誤的系統性因素
- CTo determine disciplinary action for the involved staff確定涉事人員的紀律處分
- DTo identify which individual nurse made the mistake識別犯錯的個別護理師
根本原因分析（Root Cause Analysis, RCA）的核心精神在於「公平文化」（Just Culture），強調將焦點從「誰犯錯」轉移到「系統哪裡出錯」。醫療錯誤往往是多重系統因素累積的結果，而非單一人員的疏失。RCA 的目標是透過剖析流程、設備、溝通與環境因子，找出防禦系統中的漏洞，並提出具體的改善措施（如增加雙重核對機制、優化藥物標示），以從根本上預防錯誤再次發生。這不僅是為了病人安全，更是為了建立一個讓員工願意主動通報錯誤的環境。
The primary goal of a root cause analysis (RCA) is to identify systemic factors that contributed to an error rather than assigning blame to individuals. This non-punitive approach focuses on improving safety systems and processes to prevent future occurrences. By addressing underlying issues such as workflow or equipment problems, healthcare organizations can enhance overall patient safety.
在美國，RCA 高度強調匿名性與「非懲罰性」（Non-punitive）原則，旨在促進醫療團隊的透明度。台灣臨床環境雖已逐漸導入 RCA，但在傳統文化影響下，有時仍較難完全脫離個人究責的氛圍。