消防機關依據消防法執行預防火災、搶救災害及緊急救護三大任務，隨著時代變遷及社會環境的改變，緊急救護勤務之數量與日俱增，桃園縣於民國98年救護出勤次數更高達63,054次。雖然桃園縣政府消防局救護服務品質屢屢獲得全國評比佳績，但仍有少部分救護異常之個案發生，其中又以分隊救護出勤反應時間延遲佔多數且最容易發生糾紛。 在了解Reason於1990年提出之瑞士乳酪理論後可以發現，一件救護異常事件的發生，出勤同仁所造成之錯誤僅能視為誘發性失誤(Active failures)，但誘發性失誤卻最容易被視為主要原因，相關人員因而遭受咎責。 本文利用根本原因分析法（RCA）找出分隊救護反應時間延遲案件之根本原因及系統潛在性失誤(Latent failures)，並設計改善方案以杜絕類似案例再度發生，提供救護患者更優質之緊急救護服務，並期許透過本文能提供各界根本原因分析法之參考。 The fire department carries out its three missions of “fire prevention”, “rescue work”, and “emergency first-aid” in accordance with fire services related laws. As time goes by, there is an increasing number of emergency medical services need to be accommodated. For example, the Fire Bureau of Taoyuan County had around sixty-three thousand emergency medical services in 2009. Although the mentioned bureau has been always in the first rank of fire service satisfaction survey, there are still some extraordinary cases, mainly related to the response interval, which might cause disputes. The main reason of an extraordinary case is usually concluded of some colleagues’ error. However, if we consider Reason’s “Swiss Cheese Theory” (1990), the error might only be the active failure, not the latent failure. In order to find out the potential failures, this research uses Root Cause Analysis (RCA) to filter out the root cause and design relevant action plans to eliminate similar risk factors.
