目的：若醫療機構發生火災且無法立即撲滅，往往可能造成嚴重的人員傷亡及財物損。本專案期能提出輻射防護病房火災應變設備及火災應變流程的改善方案。方法：本專案由院長室、企劃室、核子醫學科、內分泌新陳代謝科、護理部、工務室、職業安全衛生室、醫療品質管制室成立專案小組，運用醫療照護失效模式與效應分析（Healthcare Failure Mode and Effects Analysis）繪製火災應變程序過程，分析潛在失效模式及失效原因後，再以風險優先係數矩陣及決策樹分析選定潛在原因進行改善。結果：火災應變流程失效模式包括疏散路線不暢通、支援人力無法即時到場救援、無法即時接獲火災通報、病人疏散後未有辨識方法且缺乏持續照護流程等。改善團隊以風險優先係數（RPN）大於8分者擬定對策，例如裝設病室火警報知機及連動系統、修訂支援單位及通報流程、導入持續通報系統、提升病人辨識可行性等。結論：專案改善後，風險優先係數總分自394分降低至111分，改善成效達72%，確實改善輻射防護病房火災應變設備及火災應變流程，並提升輻射防護病房照護團隊及鄰近單位的火災應變能力。

Objectives: If a fire breaks out in a medical institution and cannot be extinguished immediately, serious personnel and property damage will occur. The purpose of this project is to improve the equipment and response procedures for a fire, and to promote the response capabilities of a medical care team and neighboring units, in an isolation room for radioactive iodine therapy. Methods: The improvement team consisted of nine members from the Superintendent's Office, Division of Planning and Management, Department of Nuclear Medicine, Endocrinology and Metabolism, Department of Nursing, Department of Engineering and Maintenance, Department of Occupational Safety and Health, and Division of Hospital Quality and Safety. Using the Healthcare Failure Mode and Effects Analysis method, the main and following processes for fire response were drawn. The failure modes and their potential causes of each process were listed accordingly. A decision tree to improve the process was also made. Results: The failure modes for fire response in the isolation room include i.) uncertain evacuation routes, ii.) no immediate supporting personnel, iii.) not receiving the fire notification instantly, and iv.) lacking patient identification and further medical care after evacuation. We developed countermeasures for potential causes of failure modes with a risk priority number (RPN) greater than eight points, e.g. installing the fire alarm system which triggers the door to open and links the information to the central control room of the hospital, changing the support units and modifying its notification processes, introducing a continuous notification system, and improving the feasibility of patient identification. Conclusions: After improvement, the RPN decreased from 394 to 111 points and the improvement effectiveness reached 72%. This project indeed improved the equipment and response procedures for a fire, and promoted the response capabilities of the medical care team and neighboring units in the isolation room.