Event Tracking Number

Form for Performing a Root cause analysis of a

Blood or Body Fluid Exposure

Description of Event Under Investigation

Event: Date / / Time AM PM Weekday:

Location:
Details of how the event occurred:

Is this a root If YES, is an

cause of the action plan
If AYES@, what contributed to this factor event? indicated?
Contributing Factors YES NO being an issue? YES NO YES NO

Issues related to patient □ □ □ □ □ □

assessment?

Issues related to staff □ □ □ □ □ □

training or staff competency?

Equipment/device? □ □ □ □ □ □

Work environment? □ □ □ □ □ □

Lack of or misinterpretation □ □ □ □ □ □
of information?

Communication? □ □ □ □ □ □

Appropriate rules/policies/ □ □ □ □ □ □
procedures or lack thereof?

Failure of a protective
barrier? □ □ □ □ □ □

Personnel or personal issues? □ □ □ □ □ □

Supervisory issues
□ □ □ □ □ □

Sharps Injury Prevention Workbook: A-9 Sample Form for Performing a Simple Root Cause Analysis Page 1 of 2
 Event Tracking Number

Root Cause Analysis Action Plan

Risk Reduction Strategies Measure(s) of Effectiveness Responsible Person(s)

Action item #1

Action item #2

Action item #3

Action item #4

Action item #5

Sharps Injury Prevention Workbook: A-9 Sample Form for Performing a Simple Root Cause Analysis Page 2 of 2
 Sample Trigger Questions for Performing a Root Cause Analysis
of a Blood or Body Fluid Exposure

1. Issues related to patient assessment 5. Was a lack of or misinterpretation of

 Was the patient agitated before the information contribute to this event?
procedure?  Did the healthcare worker misinterpret
 Was the patient cooperative before any information about the procedure
the procedure? that could have contributed to the
 Did the patient contribute in any way event?
toward the event?
6. Communication
2. Issues related to staff training or staff  Were there any communication
competency barriers that contributed to this event
 Did the healthcare worker receive (e.g., language)
training on injury prevention technique  Was communication in any way a
for the procedure performed? contributing factor in this event?
 Are there training or competency
factors that contributed to this event? 7. Appropriate policies/procedures
 Approximately how many procedures  Are there existing policies or
of this type has the healthcare worker procedures that describe how this
performed in the last month/week? event should be prevented?
 Were the appropriate policies or
3. Issues related to the device procedures followed?
 Did the type of device used contribute  If they were not followed, why not?
in any way to this event?
 Was a “safety” device used? 8. Worker issues
 If not, is it likely that a safety device  Did being right or left handed
could have prevented this event? influence the risk?
 On the day of the exposure, how long
4. Work environment had the worker been working before
 Did the location, fullness or lack of a the exposure occurred?
sharps container contribute to this  At the time of the exposure, could
event? factors such as worker fatigue,
 Did the organization of the work hunger, illness, etc. have contributed?
environment (e.g., placement of
supplies, position of patient) influence 9. Employer issues
the risk of injury?  Did lack of supervision contribute to
 Was there sufficient lighting? this event?
 Was crowding a factor?
 Was there a sense of urgency to
complete the procedure?

Sharps Injury Prevention Workbook: A-9 Sample Form for Performing a Simple Root Cause Analysis Page 2 of 2