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一名護理長與病房團隊討論病人安全文化,因近期發生一起投藥錯誤已抵達病人但無傷害。依據Just Culture原則與never-event通報,護理長應採取的行動為?(複選)

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1 Review system safeguards and update policies as indicated 檢討系統防護機制並依需要更新政策 2 Notify the client and family per facility disclosure policy 依機構公開政策通知病人與家屬 3 Counsel the involved nurse to determine whether the behavior was human error, at-risk, or reckless 與當事護理師面談,判別行為屬人為失誤、冒險行為或魯莽行為 4 Submit a non-punitive incident report focused on system factors 提交聚焦系統因素之非懲罰性事件通報 5 Conduct a root cause analysis with the involved team 與相關團隊共同進行根本原因分析(RCA) 6 Suspend the involved nurse pending investigation regardless of the behavior pattern 不論行為類別皆於調查期間停職當事護理師

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