RCA Root Cause Analysis and Action Plan grid

Confidential & Protected information

under California Code of Civil Procedure

Section 425.16

Level of Analysis

Questions

Findings

Root

Cause?

Ask

“Why?”

Take

Action

What happened?

Sentinel Event

What are the details of the event? (brief description)

When did the event occur? (date, day of week, time)

What area/service was impacted?

Was incident disclosed to patient/family?

Why did it happen?

The process or activity in which the event occurred.

What are the steps in the process, as designed?

What were the most proximate factors?

(Typically “special cause” variation)

Human factors

What human factors were relevant to the outcome?

1. Were issues related to patient assessment a factor in this situation?

2. Was a lack of information or misinterpretation a 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 environmental factors

What factors directly affected the outcome?

Uncontrollable external factors

Are they truly beyond the organization’s control?

Other

Are there any other factors that have directly influenced this outcome?

What other areas or services are impacted?

Why did that happen? What systems and processes underlie those proximate factors?

(Common cause variation here may lead to special cause variation in dependent processes)

Human Resources issues

To what degree are staff properly qualified and currently competent for their responsibilities?

How did actual staffing compare with ideal levels?

What are the plans for dealing with contingencies that would tend to reduce effective staffing levels?

How can orientation and in-service training be improved?

Information management issues

To what degree is all necessary information available when needed? Accurate? Complete? Unambiguous?

To what degree is communication among participants adequate?

Environmental management issues

To what degree was the physical environment 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:

- Corporate culture

To what degree is the culture conducive to risk identification and reduction?

- Encouragement

of communication

What are the barriers to communication of potential risk factors?

- Clear

communication

of priorities

To what degree is the prevention of adverse outcomes communicated as a high priority? How?

Uncontrollable factors

What can be done to protect against the effects of these uncontrollable factors?

Action Plan

Risk Reduction Strategies

Measures of Effectiveness

For each of the findings identified in the analysis as needing an action, indicate the planned action expected, implementation date and associated measure of effectiveness. OR …

1. Assessment

2. Information

3. Communication

4. Policy & procedure

5. Training

Action Item #1:

Responsible Person(s):

Timeframe for completion:

If after consideration of such a finding, a decision is made not to implement an associated risk reduction strategy, indicate the rationale for not taking action at this time.

Action Item #2:

Responsible Person(s):

Time frame for completion:

Check to be sure that the selected measure will provide data that will permit assessment of the effectiveness of the action.

Action Item #3:

Responsible Person(s):

Time frame for completion:

Consider whether pilot testing of a planned improvement should be conducted.

Action Item #4:

Responsible Person(s):

Time frame for completion:

Improvements to reduce risk should ultimately be implemented in all areas where applicable, not just where the event occurred. Identify where the improvements will be implemented.

Action Item #5:

Responsible Person(s):

Time frame for completion:

Cite any books or journal articles that were considered in developing this analysis and action plan: