本研究主要是在探討醫療轉診事件，腦部受到重創需要緊急醫治被由醫療資源最豐沛之臺北市遠送到一百多公里外之臺中縣進行急救，公務機關未在第一時間作適當處理，延誤就醫致死，案經媒體報導轉診失當，影響機關組織的形象並陷入危機。我國緊急醫療體系在經歷921震災、SARS風暴後更加凸顯了其應變資訊與指揮協調的重要性，尤其是災難發生時往往需要鄰近縣市之合作與協助，如何針對鄰近縣市從消防救災、緊急醫療體系的水平，啟動配合中央、地方層級的垂直指揮提升緊急醫療體系應變能力、達成有效之醫療與救災是現今重要的課題。本研究為能簡單明瞭並掌握危機處理之精髓，決定採用三階段的危機管理，即危機前的預防、危機中的處理及危機後的管理模式予以分析，並分為五大步驟說明處理過程，其內容為危機訊息的偵測、危機的準備及預防、損害的控制及處理、復原工作的進行、不斷學習及修正等五大步驟，配合研究架構管理區分階段及方法步驟因應危機管理機制。轉診危機事件僅是危機類型表現之一種方式，個案危機事件又僅是滄海一粟，尚未爆發與正在形成的危機仍有數以千計在機關的忽視下而逐漸進行著著，故更應模擬各類危機情況的發生，檢視各單位危機應變計畫與相應之管理系統增加公部門處理危機能力。 This study primarily is to explore the medical treatment referral incident: A patient who suffered severe head wound which demanded emergency medical treatment. And this patient was transferred to a hundred kilometers away Taichung County from an abundant medical resource Taipei City for emergency operation. Moreover appropriate government agency did not follow the proper procedure at the first instant of this incident which caused fatality from this delayed medical treatment. Worst still, this case was reported in the media and labeled as malpractice of the medical treatment referral which negatively impacted the image of government agency and rendered the agency into crisis mode. Our national emergency medical system, after experiencing onslaughts of 921 quakes and the storm of SARS, underscored the importance of countermeasure information and the command coordination, especially when the disaster occurs it normally requires the cooperation and assistance provided by neighboring counties and cities. They primarily can be summarized as to how to target to the neighboring counties and cities specifically as to how to raise their levels in fire protection rescue and emergency medical system so as to activate these services in order to work in conjunction with the vertical command structure stemmed from central and local governments. Thus raising the countermeasure capability of emergency medical system so as to achieve effective medical and rescuing mission objectives has become the nowadays important topic. This study intends to be simple and straightforward in addition to having a good command of the essence of crisis management. Thus it decides to adopt the three-phased crisis management, i.e. the prevention measures prior occurrence of the crisis, the process during the crisis as well as analyzing the management mode during the aftermath of the crisis. In addition all of these will be separated into five major procedures to illustrate how the processes proceed forward. And the contents of these comprise of: detection of crisis message, preparation and prevention of the crisis, damage control and process, the proceeding of restoration work, constant learning and rectification, etc, a total of five procedures. And these are meant to work in conjunction with the research structure management and distinctive stages as well as the methods and procedures counteracting the demands from crisis management mechanism. Medical treatment referral event is only one of the ways in expressing the crisis types encountered. And individual crisis event is only a very small portion as opposed to all. Crises that are not manifested and in the process of becoming one are countless; and they are ignored by appropriate government agencies and are still ongoing. Therefore it is necessary to simulate the occurrence of all emergencies and review the emergency countermeasure plans as well as the public crisis management capabilities added to corresponding management systems.