目的：肥胖病人手術風險高於一般病人，從手術結束到病人轉移位過程，具有造成病人傷害與醫護人員肌肉骨骼傷害之潛在性風險。藉由根本原因分析（RCA²）得以找出造成肥胖病人術後轉移位照護系統失效的根本原因，並建構術後轉移位作業之流程，減少轉移位異常事件發生。方法：2015年6月成立RCA²團隊，探討肥胖病人發生術後轉移位滑落之根本原因，佐以建構轉移位標準化作業流程規範，措施介入後檢視臨床成效。結果：本專案由2015年6月進行至2016年8月，措施介入後於2016年5月∼8月轉移位作業執行率為96.1%，病人術後因轉移位發生異常事件為0件。結論：運用RCA²方法能有效找到問題，以進行品質改善，建構安全轉移位作業並確實執行，提升手術病人安全，杜絕異常事件發生。

Objectives: Patients with obesity face increased risks in operations. Moreover, during the postoperative patient handling procedure, potential risks that may cause patient injuries and caregiver muscle or bone injuries exist. Hence, the present study used the root cause analysis squared (RCA²) to identify the root causes for the ineffective postoperative patient handling practices and establish a standardized set of postoperative patient handling procedures to reduce the occurrence of adverse events during the patient handling procedures. Methods: An RCA² team was formed in June, 2015, to identify the root causes for patient slippage during the postoperative handling period, and also to establish standardized procedures for the handling and determine the clinical effectiveness of such interventions. Results: The project lasted from June, 2015 to August, 2016. After the introduction of the intervention, among the patient handling procedures, which had an executive rate of 96.1% from May to August, 2016, no instances of handling-related adverse events occurred. Conclusions: The RCA² is an effective tool to locate possible causes of problems in an effort to improve service quality, establish and implement safe patient handling procedures, enhance patients' safety in the postoperative period, and prevent adverse events.