ROOT CAUSE ANALYSIS REPORT

ORGANIZATION
AGENCY

REFERENCE NUMBER

PROGRAM/FACILITY

REGION

CONSUMER ID

AGE:

CONSUMER DETAILS GENDER:

CITY/TOWN:

DATE OF EVENT: DATE RCA COMPLETED:

EVENT DETAILS
EVENT DESCRIPTION LIST RCA TEAM MEMBERS
Describe the event and include any harm that resulted. Also identify the cause, if known.

TEAM LEADER:

BACKGROUND SUMMARY
Answer these questions with a brief summary. Attach supporting documents, if available.
Describe the event, and include any harm that resulted. Also identify the cause, if known. Description:

Was there any deviation from the expected sequence? If YES, explain the deviation.
YES

NO

If deviation occurred from the expected sequence, was it likely If YES, explain the contribution.
to have contributed to the adverse event? YES

NO

UNKNOWN

Was the expected sequence described in policy, procedure, If YES, explain the source.
written guidelines, or included in staff training? YES

NO

UNKNOWN

Does the expected sequence meet regulatory requirements If YES, define references and/or literature reviewed by the
and/or practice standards? YES team.

NO

UNKNOWN
Was there a human action or inaction that contributed to the If YES, explain how the actions contributed.
adverse event? YES

NO

UNKNOWN

Was there a defect, malfunction, misuse of, or absence of If YES, describe the equipment and how it appeared to
equipment that contributed to this event? YES contribute.

NO

UNKNOWN

Did the procedure/activity involved in the event being carried If NO, explain where and why a different location was
out take place in the usual location? YES utilized.

NO

UNKNOWN

Was the procedure/activity carried out by regular staff familiar If NO, describe who carried out the activity and why
with the consumer and activity? YES regular staff were not involved.

NO

UNKNOWN

Did the involved staff have the correct credentials and skills to If NO, explain the perceived inadequacy.
carry out the tasks expected of them? YES

NO

UNKNOWN
Was the staff trained to carry out their expected If NO, explain the perceived inadequacy.
responsibilities? YES

NO

UNKNOWN

Were the staffing levels considered adequate at the time of the If NO, explain why.
incident? YES

NO

UNKNOWN

Were there any additional staffing factors identified as If YES, explain those factors.
responsible for or contributing to the adverse event? YES

NO

UNKNOWN

Was there any inaccurate or ambiguous information that If YES, explain what information and how it contributed.
contributed to or caused the adverse event? YES

NO

UNKNOWN

Was there any lack of communication or incomplete If YES, explain who, what, and how it contributed.
communication that contributed to or caused the adverse YES
event?
NO

UNKNOWN
Were there any environmental factors that contributed to or If YES, explain what factors and how they contributed.
caused the adverse event? YES

NO

UNKNOWN

Were there any organizational or leadership factors If YES, explain what factors and how they contributed.
contributing to or causing the adverse event? YES

NO

UNKNOWN

Were there any assessment or planning factors that contributed If YES, explain the factors and how they contributed.
to or caused the adverse event? YES

NO

UNKNOWN

Were there any other factors that are considered relevant to the Describe:
adverse event? YES

NO

UNKNOWN
 Rank in order the factors considered responsible for the adverse event, beginning with the proximate cause, followed by the most important to less important contributory
factors. Attach the Contributory Factors Diagram, if available.

Was there a root cause identified? If YES, explain the root cause.
YES

NO

UNKNOWN

RISK-REDUCTION ACTIONS TAKEN

List the actions that have already been taken to reduce the risk of a future occurrence. Note the date of implementation.

DATE EXPLAIN ACTION TAKEN

List the recommended actions planned to prevent a future occurrence of the adverse event. Begin with a rank of 1 (highest). Provide an estimated cost (if known) and any
additional considerations/recommendations for implementing the strategy.

STRATEGY ESTIMATED COST SPECIAL CONSIDERATIONS

INCIDENTAL FINDINGS

List and explain any incidental findings that should be carefully reviewed for corrective action.
 APPROVAL
After review of this summary report, all team members should notify the team leader of either their approval or recommendations for revision. Following all revisions,
the report should be signed by the team leader prior to submission.

SIGNATURE OF TEAM MEMBER: DATE SIGNED:

All information included in this report is considered confidential. It is intended only to promote safety and reduce risk.

Forward completed report to all Root Cause Analysis team members in addition to the following individuals:

FULL NAME TITLE/ORGANIZATION EMAIL ADDRESS