:

(Patient Safety) (error) (bias)(accident)

C-PAPCPR 10:45BP: 173/102 mmHgSPO2:97%C-PAP10:50AM10:55AMC-PAPCALLCPR 10

-

medical error

1.2. )_

medication error

medical negligencesystem errors Latent error

- sentinel event

accidentincident

critical incident

incident reportingnear miss

medical adverse event

no harm event

(1)(1997-1998)180041985-20001995150,0112000270,460(AHRQ,1999)88IOM1999170

(2)20011987-19992,409(18%)(14.1%)(11.4%)(9.4%)1,54170232.8%29.1%15.4%11.7%

(3)

3200113200

(Swiss cheese model)1990Reason

Tom & Jerry

/

---(Do no harm)

SEPTEE(Safety) (Effectiveness) (Patient Center)

(Timeliness) (Efficient) (Equity)

InputProcessOutputEvaluation

1Technical qualityeffectiveness

2Interpersonal qualityprivacyconfidentialityinformed choiceconcernempathyhonestytactsensitivity

3Amenities qualityAccess

PDCA

ADR

//

/()

http://129.34.1.15/--(//)http://www.tpr.org.tw/PatientSafty02/framIndex.htm

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