ROOT CAUSE ANALYSIS AND ACTION PLAN

Incident Number: Patient Name/Number:

Date Incident Occurred: Time Incident Occurred:
Where Incident Occurred: Date RCA Completed:

Detailed Incident Description Including Timeline:

Prompts Root Cause Analysis

# Analysis Question Plan of Action
Findings
Why was the wrong dose
1. administered to the
patient?
Were there any steps in
2. the process that did not
occur as intended?
3. What human factors were
relevant to the outcome?
How did the equipment
4. performance affect the
outcome?
What controllable
environmental factors
5.
directly affected this
outcome?
What uncontrollable
6. external factors influenced
this outcome?
Were there any other
7. factors that directly
influenced this outcome?
What are the other areas in
8. the organization where
this could happen?
Was the staff properly
qualified and competent
9.
for their responsibilities at
the time of the event?
How did actual staffing
10.
compare with ideal levels?

Root Cause Analysis Code: DHGH-TQM-RCA-FO: 01 Issue No: 2 Issue Date: 01/12/2017 Revision date: 01/12/2019 Next revision date: 01/12/2021
 Prompts Root Cause Analysis
# Analysis Question Plan of Action
Findings
What is the plan for
11. dealing with staffing
contingencies?
Were such contingencies a
12.
factor in this event?
Did staff performance
13. during the event meet
expectations?
To what degree was all the
necessary information
14. available when needed?
Accurate? Complete?
Unambiguous?
To what degree was the
communication among
15.
participants adequate for
this situation?
Was this the appropriate
physical environment for
16.
the processes being
carried out?
What systems are in place
17. to identify environmental
risks?
What emergency and
failure- mode responses
18. have been planned and
tested?

How does the

19. organization’s culture
support risk reduction?
What are the barriers to
20. communication of
potential risk factors?
How is the prevention of
adverse outcomes
21.
communicated as a high
priority?
22. How can staff orientation
and in-service training be
revised to reduce the risk

Root Cause Analysis Code: DHGH-TQM-RCA-FO: 01 Issue No: 2 Issue Date: 01/12/2017 Revision date: 01/12/2019 Next revision date: 01/12/2021
 Prompts Root Cause Analysis
# Analysis Question Plan of Action
Findings
of such events in the
future?
Was available technology
23.
used as intended?
How might technology be
introduced or redesigned
24.
to reduce risk in the
future?

Root Cause Analysis Code: DHGH-TQM-RCA-FO: 01 Issue No: 2 Issue Date: 01/12/2017 Revision date: 01/12/2019 Next revision date: 01/12/2021
 5 WHYS ANALYSIS
Problem Statement: ??

1. WHY?


2. WHY?


3. WHY?


4. WHY?


5. WHY?


Root Cause Analysis Code: DHGH-TQM-RCA-FO: 01 Issue No: 2 Issue Date: 01/12/2017 Revision date: 01/12/2019 Next revision date: 01/12/2021
 FISHBONE ANALYSIS
The Quality Improvement Team identified many possible reasons through observation, staff interviews and brainstorming sessions. Our findings
are plotted below using a fishbone model.

People Environment

Cause 1 Cause 1

Cause 2 Cause 2

Cause 3 Cause 3

Effect

Cause 1 Cause 1 Cause 1

Cause 2 Cause 2 Cause 2

Cause 3 Cause 3 Cause 3

Materials Methods Equipment

Root Cause Analysis Code: DHGH-TQM-RCA-FO: 01 Issue No: 2 Issue Date: 01/12/2017 Revision date: 01/12/2019 Next revision date: 01/12/2021
 Action Plan
Participants in Root Cause Analysis: Conclusions/Recommendations:

Cite all books and journal articles that

were considered in developing this root
cause analysis and action plan

For Quality Department use:

Action Taken: □ Satisfactory □ Unsatisfactory

Remarks:

Quality Director: Signature: Date:

Root Cause Analysis Code: DHGH-TQM-RCA-FO: 01 Issue No: 2 Issue Date: 01/12/2017 Revision date: 01/12/2019 Next revision date: 01/12/2021