ROOT CAUSE ANALYSIS REPORT

ORGANIZATION
AGENCY
REFERENCE NUMBER
PROGRAM/FACILITY
REGION
CONSUMER ID
CONSUMER DETAILS	AGE:
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?	YES NO	If YES, explain the deviation.
If deviation occurred from the expected sequence, was it likely to have contributed to the adverse event?	YES NO UNKNOWN	If YES, explain the contribution.
Was the expected sequence described in policy, procedure, written guidelines, or included in staff training?	YES NO UNKNOWN	If YES, explain the source.
Does the expected sequence meet regulatory requirements and/or practice standards?	YES NO UNKNOWN	If YES, define references and/or literature reviewed by the team.
Was there a human action or inaction that contributed to the adverse event?	YES NO UNKNOWN	If YES, explain how the actions contributed.
Was there a defect, malfunction, misuse of, or absence of equipment that contributed to this event?	YES NO UNKNOWN	If YES, describe the equipment and how it appeared to contribute.
Did the procedure/activity involved in the event being carried out take place in the usual location?	YES NO UNKNOWN	If NO, explain where and why a different location was utilized.
Was the procedure/activity carried out by regular staff familiar with the consumer and activity?	YES NO UNKNOWN	If NO, describe who carried out the activity and why regular staff were not involved.
Did the involved staff have the correct credentials and skills to carry out the tasks expected of them?	YES NO UNKNOWN	If NO, explain the perceived inadequacy.
Was the staff trained to carry out their expected responsibilities?	YES NO UNKNOWN	If NO, explain the perceived inadequacy.
Were the staffing levels considered adequate at the time of the incident?	YES NO UNKNOWN	If NO, explain why.
Were there any additional staffing factors identified as responsible for or contributing to the adverse event?	YES NO UNKNOWN	If YES, explain those factors.
Was there any inaccurate or ambiguous information that contributed to or caused the adverse event?	YES NO UNKNOWN	If YES, explain what information and how it contributed.
Was there any lack of communication or incomplete communication that contributed to or caused the adverse event?	YES NO UNKNOWN	If YES, explain who, what, and how it contributed.
Were there any environmental factors that contributed to or caused the adverse event?	YES NO UNKNOWN	If YES, explain what factors and how they contributed.
Were there any organizational or leadership factors contributing to or causing the adverse event?	YES NO UNKNOWN	If YES, explain what factors and how they contributed.
Were there any assessment or planning factors that contributed to or caused the adverse event?	YES NO UNKNOWN	If YES, explain the factors and how they contributed.
Were there any other factors that are considered relevant to the adverse event?	YES NO UNKNOWN	Describe:

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?	YES NO UNKNOWN	If YES, explain the root cause.

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

PREVENTION STRATEGIES
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