醫療事故往往具有系統性特徵。所謂系統性特徵係指行為人之過失僅係事故發生的表因，真正的原因乃係組織體內所存在的系統障礙。例如，執刀醫師之所以會不小心將紗布遺留在病人體內，看似屬其個人過失，其實係肇因於其遵從醫療院所等組織體之規則與安排而不得不連續值班長達48小時之過勞所致。此處值得我們深思的是，刑法只處罰行為人，公平嗎？易言之，刑法究竟應如何評價系統性醫療事故中的醫護人員的個人過失責任方屬適當？要之，本文之目的即在於，從醫療事故之「系統性特徵」中所呈現出來之「法律評價與醫療現場的落差」為切入視角，來重新思考醫師於醫療事故中所應負擔之過失的注意義務之具體內涵究竟為何，並進一步指出問題解決的可能方向。

Medical accidents often have systemic features. The so-called systemic features means that human error is only a proximate cause of the accident, and the real reason is the system errors in the organization. For example, let’s think about the case of a surgeon put the gauze in the patient’s body carelessly. The reason of the medical accident in this case seems to be a personal fault of the surgeon’s human error, but, in fact, the real reason is overwork because of the system errors in the hospital. Is it fair that the criminal law only punishes the surgeon? The question is certainly worth our careful consideration. The purpose of this paper is to rethink the reasonable evaluation of criminal negligence of medical staffs in system medical accidents from the viewpoint of “mismatch between legal assessment and practical sense of the medical field”, and then, further points out possible pathways to solve the problem of the mismatch between legal assessment and practical sense of the medical field.