台大醫院醫療疏失個案：危機管理觀點

Case Study on Medical Negligence at National Taiwan University Hospital: A Crisis Management Perspective

台大醫院曾發生加護病房洗腎接錯管事件，然醫療疏失不同於一般的服務疏失，難以單純由服務補救策略予以處理。故本個案從危機管理與溝通觀點出發，首先解析該醫療疏失事件發生的原因、經過與危機處理過程，說明一般服務失誤與醫療疏失不同，再以危機管理三階段 (危機前的預防與準備、危機中的處理與溝通、危機後的組織學習) 為教學主軸，規劃相關理論概念讓學生學習到危機管理之重要性，並認識危機是可預防的，以及其預防之道。同時也傳遞醫療危機溝通的第一要務，乃在保護利害關係人免於受到傷害而非汲汲營營於維護自身聲譽。

An intensive care unit of National Taiwan University Hospital committed medical negligence in which the wrong tube was used for dialysis treatment. Differing from other types of service negligence, cases of medical negligence cannot be resolved solely by means of service recovery strategies. As a consequence, this case used crisis management and communication as a basis to first analyze the reasons why medical negligence occurred at this hospital, and then adopted the perspective of the crisis management process to explain the difference between general service errors and medical negligence. Additionally, the three stages of crisis management (pre-crisis prevention and preparation, crisis management and communication, and post-crisis organizational learning) are presented and used as teaching axes and related theories and concepts are provided to help students understand the importance of crisis management, recognize that crisis can be prevented, and identify avenues for prevention. At the same time, this case conveys to students the message that the first priority of medical crisis communication is to protect stakeholders from harm, rather than striving to protect organizational reputation.