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第6階段 — 評估結果。審查血糖和安全反應軌跡，然後回答關於復發、事件分類和系統有效性的三個問題。

Trend

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Time	Data
0430 — Exposure	Point-of-care glucose 286 mg/dL. Paper downtime order reads regular insulin 10U subcutaneously; 100 units are administered.床邊血糖286 mg/dL。紙本停機醫囑為皮下注射常規胰島素10單位；實際施打100單位。
0500 — Initial hypoglycemia	Diaphoresis, tremor, confusion, and point-of-care glucose 38 mg/dL. Rapid response and hypoglycemia protocol are activated; IV dextrose is given through a patent IV.出汗、顫抖、意識混亂，床邊血糖38 mg/dL。啟動快速反應和低血糖處置流程；透過通暢的靜脈輸液給予靜脈葡萄糖。
0530 to 0600 — Recurrence	Glucose rises to 112 mg/dL, then falls to 78 mg/dL at 0545 and 62 mg/dL with recurrent diaphoresis at 0600. The team treats again, adjusts ordered dextrose support, and continues point-of-care and potassium monitoring.血糖升至112 mg/dL，隨後在0545降至78 mg/dL，並在0600伴隨復發性出汗降至62 mg/dL。團隊再次治療，調整醫囑中的葡萄糖支持，並持續床邊和鉀離子監測。
Later observation — Sustained stability	Glucose remains 104 to 156 mg/dL during a sustained observation period without recurrent symptoms or neurologic deficit. Discharge and the insulin plan are reassessed.在持續觀察期間，血糖維持在104至156 mg/dL，無復發症狀或神經功能缺損。重新評估出院和胰島素計畫。
30 days — System follow-up	The unit audits downtime orders for spelled-out units, reconciliation after EHR restoration, high-dose alert overrides, barcode exceptions, policy-defined checks, event trends, and staff reporting volume.單位稽核停機醫囑中單位是否拼寫完整、電子健康紀錄（EHR）恢復後的核對、高劑量警報覆蓋、條碼異常、政策規定的檢查、事件趨勢和員工報告量。

Q1. How should the 0530-to-0600 glucose trend be interpreted?0530至0600的血糖趨勢應如何解讀？

The first normal value proves the overdose has fully resolved第一個正常值證明過量已完全解決 The falling values and recurrent symptoms show ongoing excess-insulin effect requiring renewed treatment and continued point-of-care monitoring下降的數值和復發的症狀顯示過量胰島素作用仍在持續，需要重新治療並持續床邊監測 The client should receive scheduled insulin immediately because the glucose briefly exceeded 100 mg/dL個案應立即接受常規胰島素，因為血糖曾短暫超過100 mg/dL

Q2. Which conclusion about event classification is most accurate?關於事件分類，哪一個結論最準確？

Every tenfold dose is automatically a Joint Commission sentinel event regardless of outcome無論結果如何，每十倍劑量都自動成為聯合委員會（Joint Commission）的警訊事件 The event cannot be reviewed unless permanent harm is proven除非證明造成永久性傷害，否則無法審查此事件 This serious event requires review, and the organization applies current death, permanent-harm, or severe-harm criteria plus applicable reporting rules before final classification此嚴重事件需要審查，機構在最終分類前會應用目前的死亡、永久性傷害或嚴重傷害標準以及適用的報告規定

Q3. Which 30-day result best supports effective system improvement?哪一個30天結果最能支持有效的系統改進？

Audits show reliable use of spelled-out units, reconciliation, alerts, barcode workflow, and policy-defined checks, with fewer unsafe orders or harms and reporting volume monitored for underreporting稽核顯示單位拼寫完整、核對、警報、條碼工作流程和政策規定檢查的可靠使用，危險醫囑或傷害減少，並監測報告量以防漏報 The unit receives fewer reports after staff are warned that every error may lead to discipline在警告員工每個錯誤都可能導致紀律處分後，單位收到的報告減少 All insulin ordering is delayed whenever the EHR is unavailable, including urgent treatment每當電子健康紀錄（EHR）不可用時，所有胰島素醫囑都會延遲，包括緊急治療

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