Confidential & Protected information

under California Code of Civil Procedure

Section 425.16 Root Cause Analysis and Action Plan MRN:
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RCA DATE:
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Attendees:

Level of Analysis Questions Findings Root Ask Take

Cause? “Why?” Action
What Sentinel Event What are the details of the event? (brief description) Mr. M was admitted in the medical surgical-unit due to Yes Yes Yes
happened? an intracapsular fracture. The night shift nurse observed
that the patient’s condition was serious than it was
reported by the day shift nurse.
When did the event occur? (date, day of week, time) April 13, 2018 at 7:46 am Yes Yes No

What area/service was impacted? The scheduled surgery was impacted by deterioration of Yes Yes Yes
the patient’s condition.
Was incident disclosed to patient/family?

Why did it The process or What are the steps in the process, as designed?
happen? activity in which the
event occurred.
What were the Human factors What human factors were relevant to the outcome?
most proximate 1. Were issues related to patient assessment a
factors? factor in this situation?
(Typically “special 2. Was a lack of information or misinterpretation a
cause” variation)
factor in this event?
3. Was communication a factor in this event?
4. Were appropriate rules/policies/procedures – or
the lack there of – a factor in this event?
5. Were issues related to staff training or staff
competency a factor in this event?
6. Was fatigue a factor in this event?
7. Was multi-tasking, interruption or distraction a
factor in this event?
Equipment factors How did the equipment performance affect the
outcome?
 Was equipment involved in this event in any
way?

Controllable What factors directly affected the outcome?

environmental factors
Uncontrollable Are they truly beyond the organization’s control?
external factors
Other Are there any other factors that have directly
influenced this outcome?
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What other areas or services are impacted?

Why did that Human Resources To what degree are staff properly qualified and
happen? What issues currently competent for their responsibilities?
systems and
processes How did actual staffing compare with ideal levels?
underlie those
proximate What are the plans for dealing with contingencies
factors? that would tend to reduce effective staffing levels?
(Common cause
variation here may
lead to special
cause variation in
dependent
processes)
How can orientation and in-service training be
improved?
Information To what degree is all necessary information available
management issues when needed? Accurate? Complete? Unambiguous?
To what degree is communication among participants
adequate?

Environmental To what degree was the physical environment

management issues appropriate for the processes being carried out?
What systems are in place to identify environmental
risks?
What emergency and failure-mode responses have
been planned and tested?
Leadership issues: To what degree is the culture conducive to risk
- Corporate culture identification and reduction?
- Encouragement What are the barriers to communication of potential
of communication risk factors?
- Clear To what degree is the prevention of adverse
communication outcomes communicated as a high priority? How?
of priorities
Uncontrollable What can be done to protect against the effects of
factors these uncontrollable factors?

Action Plan Risk Reduction Strategies Measures of Effectiveness

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For each of the findings identified in the Action Item #1:

analysis as needing an action, indicate the
planned action expected, implementation
date and associated measure of
effectiveness. OR …
1. Assessment
Responsible Person(s):
2. Information
3. Communication
4. Policy & procedure Timeframe for completion:
5. Training
If after consideration of such a finding, a Action Item #2:
decision is made not to implement an
associated risk reduction strategy, indicate Responsible Person(s):
the rationale for not taking action at this time.
Time frame for completion:

Check to be sure that the selected measure Action Item #3:

will provide data that will permit assessment
of the effectiveness of the action. Responsible Person(s):

Time frame for completion:

Consider whether pilot testing of a planned Action Item #4:

improvement should be conducted.
Responsible Person(s):

Time frame for completion:

Improvements to reduce risk should Action Item #5:

ultimately be implemented in all areas where
applicable, not just where the event occurred. Responsible Person(s):
Identify where the improvements will be
implemented. Time frame for completion:

Cite any books or journal articles that were considered in developing this analysis and action plan:
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Information Protected under California Code of Civil Procedure, Section 425.16