目標：非預期的病危事件包括由一般病房非預期轉到加護病房（ICU）以及於一般病房治療後的意外死亡，在這樣非預期危及生命事件中的不良事件與錯誤有怎樣的特徵尚未被完全的了解。因此我們進行了這項研究，藉由監測這些非預期危及生命事件當作觸發工具以獲得影響病人安全的醫療錯誤和不良事件的資訊。

方法：藉由前瞻性觀察法的方式，將台灣某醫學中心由急診轉入病房於24小時內發生非預期危及生命事件的非創傷患者納入研究對象。研究期間為一年（2013年）;回溯患者的住院病歷以鑑別不良事件和醫療錯誤。本研究統計不良事件或錯誤的發生率，研究不良事件的可預防性、類型和生理傷害嚴重程度。

結果：在這一年內的成人轉入非創傷病房共33224例，有100例住院病人（0.3％）符合研究條件。醫療錯誤和不良事件發生率分別為2％和15％。在涉及醫療錯誤的病例中都是可以預防的，醫療錯誤的類型為錯誤評估。在涉及不良事件的病例中93.3％是可以預防的，其中20％的病人死亡，60％發生嚴重生理傷害。不良事件類型為診斷問題（53.3％），管理問題（40％）和藥物不良事件（6.7％）。

結論：藉由監測急診入院24小時內發生非預期的危及生命事件可為識別造成嚴重生理傷害且可預防之不良事件的有效方法。

Objectives: Errors and adverse events associated with unexpected life-threatening events including unplanned transfer to the intensive care unit (ICU) and unexpected death after emergency department (ED) hospitalization are not well characterized. We performed this study to investigate the role of unexpected life-threatening events as a trigger to capture errors and adverse events for ED patient safety.
Methods: This prospective observational study enrolled adult non-trauma patients with unexpected life-threatening events within 24 h of general ward admission from the ED of a medical center in Taiwan. The period of study was one year (in 2013); the medical records of enrolled patients were reviewed to identify adverse events and errors. We measured the incidence rate of adverse events or errors. Preventability, type, and physical injury severity of adverse events were investigated.
Results: Of 33,224 adult non-trauma ward admissions from the ED, 100 admissions (0.3%) met the study criteria. Incidence rate was 2% and 15% for errors and adverse events, respectively. In admissions involving error, all were preventable and the error type was overlooked of severity. In admissions that involved adverse events, 93.3% were preventable. There were 20% of admissions that resulted in death and 60% developed with severe physical injury. The adverse event types were diagnosis issues (53.3%), management issues (40%), and medication ad­ verse events (6.7%).
Conclusions: Unexpected life-threatening events within 24 h of admission from the ED could be a useful trigger tool to identify preventable adverse events with serious physical injury in ED.

目 錄
論文審定書…………………………………………………………… i
誌謝…………………………………………………………………… ii
中文摘要………………………………………………………….….. iv
英文摘要………………………………………..……………………. vi
第 一 章 背景與動機………………………………………………… 1
第 二 章 文獻探討……………………………………………………. 5
第 三 章 研究方法………………………………………………….… 9
第 四 章 研究結果……………………………………………………12
第 五 章 討論…………………………………………………………16
第 六 章 結論………………………………………………………....21
參考文獻……………………………………………………….……...…22

英文文獻：
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