Root Cause Analysis Worksheet 1
NSG/468 Version 1
Complete the table below to analyze the Week 4 case study. The analysis questions in the table have been adapted from The Joint Commission’s
Root Cause Analysis and Action Plan Framework you reviewed in this week’s learning activity.
Analysis Questions
What was the intended process flow?
Were there any steps in the process
that did not occur as intended?
What human factors were relevant to
the outcome?
How did the equipment performance
affect the outcome?
What controllable environmental
factors directly affected this outcome?
What uncontrollable external factors
influenced this outcome?
Were there any other factors that
directly influenced this outcome?
What are the other areas in the
organization where this could happen?
Source: The Joint Commission ROOT CAUSE ANALYSIS AND ACTION PLAN FRAMEWORK TEMPLATE. Revised 3/22/13.
Accessed 10/07/2015: http://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_action_plan/
Medication Mishap Root Cause Analysis Worksheet
Root Cause
Considerations Root Cause Analysis Findings
(Y/N)
-Identify the potential causal factors
List the relevant process steps as defined
-Identify the root cause
by the policy, procedure, protocol, or Y
-Identify the obstacles to communication
guidelines in effect at the time of the event.
-Priority of communication obstacles.
The potential causal variables were not identified
Explain in detail any deviation from the
as the patient was subjected to medications of Y
intended processes.
higher dosage and standard.
Staff-related human performance factors
Nausea. Y
such as fatigue, distraction, etc.
The equipment offered a variety of choices for the
Consider all medical equipment and medication to be prescribed, making it difficult for
N
devices. the physician to select the right one to provide to
the patient.
Consider things such as overhead paging
that cannot be heard or safety or security Communication. Y
risks.
Factors the organization cannot change The patient's information and education. N
Communication of knowledge regarding
Internal factors N
medicine.
List where the potential exists for similar Pharmacy
Y
circumstances. Injection site

Analysis Questions
Was the staff properly qualified and
currently competent for their
responsibilities at the time of the
event?
How did actual staffing compare with
ideal levels?
What is the plan for dealing with
staffing contingencies?
Were such contingencies a factor in
this event?
Did staff performance during the event
meet expectations?
To what degree was all the necessary
information available when needed?
Accurate? Complete? Unambiguous?
To what degree was the
communication among participants
adequate for this situation?
Was this the appropriate physical
environment for the processes being
carried out for this situation?
What systems are in place to identify
environmental risks?
What emergency and failure-mode
responses have been planned and
tested?
Source: The Joint Commission ROOT CAUSE ANALYSIS AND ACTION PLAN FRAMEWORK TEMPLATE. Revised 3/22/13.
Accessed 10/07/2015: http://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_action_plan/
Root Cause Analysis Worksheet 2
NSG/468 Version 1
Root Cause
Considerations Root Cause Analysis Findings
(Y/N)
Evaluate processes in place to ensure staff
N/A N/A
is competent and qualified.
Include ideal staffing ratios and actual
N/A N/A
staffing ratios along with unit census.
What the organization does during a
N/A N/A
staffing crisis
If alternative staff used, verify competency
N/A N/A
and environmental familiarity.
To what extent did staff perform as
Yes, as they did their duty to revive the patient
expected within or outside of the Y
while he was unconscious.
processes?
Patient assessments were complete, All the knowledge needed for that patient's
shared and accessed by members of the history of medication usage made it easier for Y
treatment team him to take the medication.
It was efficient as the pharmacist did confirm the
medication when the physician selected it which
Analysis of factors related to team
was to be offered to the patient. Moreover, while
communication and communication Y
the patient was unconscious, he was taken good
methods
care of and also given medicine until he got
better.
Proactively manage the patient care Yes, it was been implemented since the person
Y
environment. was given a solution to what disturbed him.
Were environmental risk assessments in "Integrated environmental risk" management
Y
place? framework was seen to be implemented.
There are numerous drills that have been
What safety evaluations and drills have
undertaken to reduce the complications that Y
been conducted?
could be triggered by the medical mishap.

Analysis Questions
How does the organization’s culture
support risk reduction?
What are the barriers to
communication of potential risk
factors?
How is the prevention of adverse
outcomes communicated as a high
priority?
How can orientation and in-service
training be revised to reduce the risk of
such events in the future?
Was available technology used as
intended?
How might technology be introduced or
redesigned to reduce risk in the future?
Source: The Joint Commission ROOT CAUSE ANALYSIS AND ACTION PLAN FRAMEWORK TEMPLATE. Revised 3/22/13.
Accessed 10/07/2015: http://www.jointcommission.org/framework_for_conducting_a_root_cause_analysis_and_action_plan/
Considerations
Does the overall culture encourage change,
suggestions, and warnings from staff
regarding risky situations or problematic
areas?
Describe specific barriers to effective
communication among caregivers.
Describe the organization’s adverse
outcome procedures.
Describe how orientation and ongoing
education needs of the staff are evaluated.
Such as: CT scanning equipment,
electronic charting, medication delivery
system, tele-radiology services
Describe any future plans for
implementation or redesign.
Root Cause Analysis Worksheet 3
NSG/468 Version 1
Root Cause
Root Cause Analysis Findings
(Y/N)
N/A N/A
The patient might have been a source of the
communication problem and provided misleading Y
information about his health status.
N/A N/A
The workers must receive serious as well as
rigorous preparation as well as a practice for the N
efficient quality of the service.
It was partly utilized for its function, although it
contributed to the administration of the wrong Y
medication to the patient.
The technology framework being used needs to
be reinforced by supplying the precise
prescription required by the physician to deliver Y
the specific drug that is necessary, as this would
reduce the chances of any medical mishap.