本專案運用根本原因分析法(Root Cause Analysis)，確認某醫學中心住院病人燙傷意外發生之根本原因為1.缺乏預防燙傷護理指導標準；2.病人對正確用熱認知不足；3.環境設備不良。專案團隊由設備資源、政策、病人、工作人員四方面，發展改善策略，包括建立高危險因子篩選表及護理指導標準、實施工作人員與病人之教育訓練、設備改善等措施。成果評值發現護理人員執行預防燙傷護理指導完整性由40%提升至100%；住院病人對預防燙傷認知程度由33.1分提升至60.4分；住院病人至今尚無燙傷意外事件再發生，已達成專案改善目標。期望分享此改善專案之經驗並推廣到各單位，加強預防燙傷護理指導，並進行環境管理達到維護病人安全目標。

This project in a Northern Taiwan medical center found by Root Cause Analysis, that the score causes for burn injury were lack of health education standards, insufficient related knowledge of patients, and improper equipment. Our team members have thus developed strategies accordingly starting with equipment, policies, patients and staff. Actual tasks include: establishing a high risk screening list and health education standards, implementing educational training programs for staff and patients, and upgrading necessary equipment. Implementation of these strategies has resulted in no further burn injury accidents for a period of five months. The accomplishment rate of health education for preventing burn injury has raised from 40% to 100%. The level of patients' burn injury prevention knowledge has raised from 33.1 to 60.4, The result has achieved the special case improvement goal, and thus the study can be a reference for other departments.