本研究以發生於某醫學中心手術室開錯部位幾近錯誤(near miss) 個案為例，以根本原因分析手法探討隱藏在手術流程中的潛在風險，釐清其根本原因。經時間序列表與因果原因樹分析後發現，此幾近錯誤之根本原因為：(1)人員電腦技巧不佳，(2)無手術病人、術式及部位確認之標準作業流程，(3)醫護人員欠缺重視病人安全之觀念。除參酌文獻建議、單位特性與人員編制，針對不同根本原因擬定合適的改善方案外，並以屏障分析評值各方案之效度。此個案研究不僅助於發掘隱藏於手術流程中的風險，提早擬定因應措施外，根本原因分析運作手法更可作為提昇醫療品質之實務參考。

This case study used Root Cause Analysis (RCA) to identify the underlying factors of anear miss of wrong-site surgery that occurred in a medical center in Taiwan. We used atabular timeline and event-and-casual-factor tree analysis to determine the 3 root factors ofthe near miss, which included bad computer skills, no standard operating procedures forpreventing wrong patient, wrong procedure, or wrong site surgery, and a lack of alertness topatient safety among healthcare workers. In order to prevent wrong-site surgery, weformulated some corrective plans according to former study suggestions, unit characteristics,and worker numbers. In addition, we used a barrier analysis to strengthen the reliability ofthe corrective plans. This case study was very helpful in identifying common weaknesses inthe operative procedures and formulating useful strategies. The process of RCA can beapplied as a practical reference to improve the quality of health care.