Root Cause Analysis
Incident Reporting & Learning System
CASE OF
:
DATE OF INCIDENT
: ( DD / MM / YYYY )
INCIDENT CODE : __________________
INTRODUCTION :
ANALYSIS & FINDINGS :
1
BRIEF
description of Incident :
Team assigned for investigation :
Name
Designation
Team Leader
Team Members
1.
Sequence of event
Date (24 h)Time Location Event description Key personinvolved &
designation Comments Eg:
1.1.11 1300H A&E Procedure X was done onthe patient
Dr. AB (HO) (Don’t state real name)
FISH BONE DIAGRAM (REFER TO LONDON PROTOCOL FOR CATEGORISATION)
* If not included in the London protocol, kindly place the contributing factor in the most suitable category provided.
EVENT CAUSAL FACTOR CHART (OPTION 1)
3
MANAGEMENT & ORGANISATIONAL FACTORS
1.
TEAM FACTORS
1.
TASK & TECHNOLOGY FACTORS
1.
INCIDENT/ ISSUE
WORK/CARE ENVIROMENT FACTORS
1. EXTERNAL FACTORS
1.
PATIENT FACTORS
1. INDIVIDUAL STAFF FACTORS
EVENT CAUSAL FACTOR CHART
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ] CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
EVENT 4 [EVENT]
[DATE & TIME] EVENT 1
[EVENT]
[DATE & TIME]
EVENT 2 [EVENT]
[DATE & TIME]
EVENT 3 [EVENT]
[DATE & TIME]
CONTINUE ON THE NEXT PAGE /
FINAL INCIDENT OR ISSUE
EVENT OR ISSUES CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ] CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
5 WHY METHOD ( OPTION 2)
(Identify problem / issue and ask why for at least 5 times to gain the root cause(s))
QUESTION : WHY ……..
ANSWER :
QUESTION : WHY ……..
ANSWER :
QUESTION : WHY ……..
ANSWER :
QUESTION : WHY ……..
ANSWER :
QUESTION : WHY ……..
ANSWER :
Recommendations
1. Root cause(s) identified.
Use the following coding :Code Factor
1 Patient Factor
2 Task and technology factor 3 Staff factor
4 Team factor
5 Work & care environment factor 6 Management and organisation factor 7 External factor
8 Other ( Unspecified )
CATEGORY OF
FACTOR
ROOT CAUSE
Examples :
4
Lack of communication between teams ( Surgical & Medical ) that reviewed the patient
6
Not enough staf
2. ACTION PLAN/ RISK REDUCTION STRATEGIES CATEGORY
CODE ACTION PLAN CATEGORY EXPLANATION & EXAMPLES OF ACTION PLAN
1 Elimination
Applicable for any action taken where the hazard is removed to prevent the reoccurrence of incident.
- Removing unnecessary step(s) in procedure or S.O.P - Removing faulty device / equipment
- Removal of hazardous material
2 Substitution
Applicable for any action taken where the hazard is substitute with a less hazardous material/ procedure.
- Replacing hazardous equipment with safer equipment.
3 Engineering control
Applicable for any action taken where technology/ engineering is used to reduce the risk of incident.
- Application of IT system for prescription of medicine to prevent medication error
- Usage of central alarm system for patient on ventilator
4 Administrative control
Usage of regulations, policies or S.O.P(s) to reduce the risk of incident
- Implementation of checklist & safe work practices - Improvement of staf rotation / shift
- Develop new policy, guideline or S.O.P - Education / CME / CNE
- Human resource
- Preventive maintained
5. Personal protective equipment Usage of protective equipment
6. Others Not included in any categories specified
No
. Root Cause ActionCode. Action Plan Person responsible Due date Review Date
Outcome
Measures Completion Date
Example :
Eg. 1
Absence of policy & education for care of patient with suicidal
risk
4
- Development of policy of care of patient with suicidal risk in
collaboration with the psychiatric dept. - Education on care of patient
with suicidal risk.
Head Of Department / Specialist
1.1.1
1 1.3.11
Availability of policy
CME/CNE done
27.2.11
10.1.11
