Objectives: Healthcare Failure Mode and Effect Analysis (HFMEA) has become an important method for quality improvement in the healthcare industry. The Taiwan Joint Commission on Hospital Accreditation and Healthcare Quality Improvement (TJCHA) lists crisis management as a required accreditation item, and suggests that hospitals take proactive measures, such as HFMEA, to establish hospital-wide risk management programs. Methods: From January 2009 to January 2011, the project consisted of the following steps: 1) define the HFMEA topics, 2) assemble the team, 3) create a flow chart, 4) conduct hazard analyses, 5) formulate action plans, and 6) measure outcomes. Using bench mark learning and brainstorming techniques, we organized a multi-disciplinary quality improvement task force. Improvement strategies including communication improvement, occupancy information transparency enforcement, and education were implemented. Results: To ensure patient safety, we used HFMEA-initiated process re-engineering to improve emergency admissions in our hospital. Nine failure modes were identified during the process analyses at the beginning of this project; they included physician and nurse communication problems, hospital admission and discharge process delay, and bed turn-over control. After intervention, hazard scores fell under 8 for all failure modes and the emergency admission rate improved significantly from 24.10% to 30.02%. Conclusions: Through team work, we effectively improved the efficiency of emergency room admissions. We will continue to monitor the safety of the emergency admission process based on the facts found as a result of this HFMEA study.