2012年10月23日署立新營醫院北門分院的護理之家，發生台灣醫療史上最嚴重的火災意外，總共疏散一百多位住院療養老人，十三人不幸往生，照護環境防火安全的老問題又再一次被檢討，特別是資源較匱乏收容大量難以移動住民的小型醫院防火安全所遭遇的火災風險；台灣各照護場域常因應醫療環境變化，利用有限醫療空間，變更醫療服務，且收容大量無自力避難病患，所面臨相關政策法令問題；以及對於老舊醫院防火安全與緊急應變的未來防範與改善等種種狀況與建議，皆是本文探討的重點。

Taiwan's worst hospital fire in history on October 23rd, 2012 at Sinying Hospital's Bei-Men Branch resulted in 13 elderly patient deaths and over 70 injuries. The heavy casualties were due in part to the serious condition of patients. Some patients on life-support machines were unable to move or be moved. This disaster highlights the issue of fire safety in small-scale hospitals that have transformed existing hospital space into special care environments for elderly patients. Compared with medical centers and general hospitals, these small-scale health facilities are ill equipped to deal properly with fire safety management and emergency response issues due to inadequate fire protection facilities, fire safety equipment, and human resources. Small-scale facilities that offer health care and medical services to mostly immobile patients face fire risks that differ significantly from general health care facilities. This paper focuses on fire risks in small-scale facilities and suggests a strategy for fire prevention and emergency response procedures, including countermeasures for fire risk assessment, management, and emergency response, in order to improve fire safety at these institutions in Taiwan.