RCA Framework

Revised 3/21/2013

ROOT CAUSE ANALYSIS AND ACTION PLAN FRAMEWORK TEMPLATE

The Joint Commission Root Cause Analysis and Action Plan tool has 24 analysis questions. The following framework is intended to provide
a template for answering the analysis questions and aid organizing the steps in a root cause analysis. All possibilities and questions should be
fully considered in seeking “root cause(s)” and opportunities for risk reduction. Not all questions will apply in every case and there may be
findings that emerge during the course of the analysis. Be sure however to enter a response in the “Root Cause Analysis Findings” field for
each question #. For each finding continue to ask “Why?” and drill down further to uncover why parts of the process occurred or didn’t occur
when they should have. Significant findings that are not identified as root causes themselves have “roots”.

As an aid to avoid “loose ends,” the two columns on the right are provided to be checked off for later reference:
 “Root cause” should be answered “Yes” or “No” for each finding. A root cause is typically a finding related to a process or system
that has a potential for redesign to reduce risk. If a particular finding is relevant to the event is not a root cause, be sure that it is
addressed later in the analysis with a “Why?” question such as “Why did it contribute to the likelihood of the event” or “Why did it
contribute to the severity of the event?” Each finding that is identified as a root cause should be considered for an action and
addressed in the action plan.
 “Plan of action” should be answered “Yes” for any finding that can reasonably be considered for a risk reduction strategy. Each item
checked in this column should be addressed later in the action plan.

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When did the event occur?

Date: Day of the week: Time:

Detailed Event Description Including Timeline:

Diagnosis:

Medications:

Autopsy Results:

Past Medical/Psychiatric History:

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1 What was the intended List the relevant process steps as defined by
process flow? the policy, procedure, protocol, or guidelines
in effect at the time of the event. You may
need to include multiple processes.
Note: The process steps as they occurred in
the event will be entered in the next question.
Examples of defined process steps may
include, but are not limited to:
 Site verification protocol
 Instrument, sponge, sharps count
procedures
 Patient identification protocol
 Assessment (pain, suicide risk,
physical, and psychological)
procedures
 Fall risk/fall prevention guidelines
2 Were there any steps in Explain in detail any deviation from the
the process that did not intended processes listed in Analysis Item #1
occur as intended? above.
3 What human factors Discuss staff-related human performance
were relevant to the factors that contributed to the event.
outcome? Examples may include, but are not limited to:
 Boredom
 Failure to follow established
policies/procedures
 Fatigue
 Inability to focus on task
 Inattentional blindness/ confirmation bias
 Personal problems
 Lack of complex critical thinking skills
 Rushing to complete task
 Substance abuse
 Trust
4 How did the equipment Consider all medical equipment and devices
performance affect the used in the course of patient care, including

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outcome? AED devices, crash carts, suction, oxygen,
instruments, monitors, infusion equipment,
etc. In your discussion, provide information
on the following, as applicable:
 Descriptions of biomedical checks
 Availability and condition of
equipment
 Descriptions of equipment with
multiple or removable pieces
 Location of equipment and its
accessibility to staff and patients
 Staff knowledge of or education on
equipment, including applicable
competencies
 Correct calibration, setting,
operation of alarms, displays, and
controls
5 What controllable What environmental factors within the
environmental factors organization’s control affected the outcome?
directly affected this Examples may include, but are not
outcome? limited to:
 Overhead paging that cannot be
heard
 Safety or security risks
 Risks involving activities of visitors
 Lighting or space issues
The response to this question may be
addressed more globally in Question #17.This
response should be specific to this event.
6 What uncontrollable Identify any factors the organization cannot
external factors change that contributed to a breakdown in the
influenced this outcome? internal process, for example natural
disasters.
7 Were there any other List any other factors not yet discussed.
factors that directly
influenced this outcome?
8 What are the other areas List all other areas in which the potential

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in the organization exists for similar circumstances. For example:
where this could  Inpatient surgery/outpatient surgery
happen?  Inpatient psychiatric care/outpatient
psychiatric care
Identification of other areas within the
organization that have the potential to impact
patient safety in a similar manner. This
information will help drive the scope of your
action plan.
9 Was the staff properly Include information on the following for all
qualified and currently staff and providers involved in the event.
competent for their Comment on the processes in place to ensure
responsibilities at the staff is competent and qualified. Examples
time of the event? may include but are not limited to:
 Orientation/training
 Competency assessment (What
competencies do the staff have and
how do you evaluate them?)
 Provider and/or staff scope of
practice concerns
 Whether the provider was
credentialed and privileged for the
care and services he or she rendered
 The credentialing and privileging
policy and procedures
 Provider and/or staff performance
issues
10 How did actual staffing Include ideal staffing ratios and actual
compare with ideal staffing ratios along with unit census at the
levels? time of the event. Note any unusual
circumstance that occurred at this time. What
process is used to determine the care area’s
staffing ratio, experience level and skill mix?
11 What is the plan for Include information on what the organization
dealing with staffing does during a staffing crisis, such as call-ins,
contingencies? bad weather or increased patient acuity.
Describe the organization’s use of alternative

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staffing. Examples may include, but are not
limited to:
 Agency nurses
 Cross training
 Float pool
 Mandatory overtime
 PRN pool
12 Were such contingencies If alternative staff were used, describe their
a factor in this event? orientation to the area, verification of
competency and environmental familiarity.
13 Did staff performance Describe whether staff performed as expected
during the event meet within or outside of the processes. To what
expectations? extent was leadership aware of any
performance deviations at the time? What
proactive surveillance processes are in place
for leadership to identify deviations from
expected processes? Include omissions in
critical thinking and/or performance
variance(s) from defined policy, procedure,
protocol and guidelines in effect at the time.
14 To what degree was all Discuss whether patient assessments were
the necessary completed, shared and accessed by members
information available of the treatment team, to include providers,
when needed? according to the organizational processes.
Accurate? Complete? Identify the information systems used during
Unambiguous? patient care.
Discuss to what extent the available patient
information (e.g. radiology studies, lab results
or medical record) was clear and sufficient to
provide an adequate summary of the patient’s
condition, treatment and response to
treatment.
Describe staff utilization and adequacy of
policy, procedure, protocol and guidelines
specific to the patient care provided.
15 To what degree was the Analysis of factors related to communication
communication among should include evaluation of verbal, written,

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participants adequate for electronic communication or the lack thereof.
this situation? Consider the following in your response, as
appropriate:
 The timing of communication of key
information
 Misunderstandings related to
language/cultural barriers, abbreviations,
terminology, etc.
 Proper completion of internal and
external hand-off communication
 Involvement of patient, family and/or
significant other
16 Was this the appropriate Consider processes that proactively manage
physical environment for the patient care environment. This response
the processes being may correlate to the response in question 6 on
carried out for this a more global scale.
situation? What evaluation tool or method is in place to
evaluate process needs and mitigate physical
and patient care environmental risks?
How are these process needs addressed
organization-wide?
Examples may include, but are not
limited to:
 alarm audibility testing
 evaluation of egress points
 patient acuity level and setting of
care managed across the continuum,
 preparation of medication outside of
pharmacy
17 What systems are in Identify environmental risk assessments.
place to identify  Does the current environment meet
environmental risks? codes, specifications, regulations?
 Does staff know how to report
environmental risks?
 Was there an environmental risk
involved in the event that was not
previously identified?

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18 What emergency and Describe variances in expected process due to
failure- mode responses an actual emergency or failure mode response
have been planned and in connection to the event.
tested? Related to this event, what safety evaluations
and drills have been conducted and at what
frequency (e.g. mock code blue, rapid
response, behavioral emergencies, patient
abduction or patient elopement)?
Emergency responses may include, but are
not limited to:
 Fire
 External disaster
 Mass casualty
 Medical emergency
Failure mode responses may include, but are
not limited to:
 Computer down time
 Diversion planning
 Facility construction
 Power loss
 Utility issues
19 How does the How does the overall culture encourage
organization’s culture change, suggestions and warnings from staff
support risk reduction? regarding risky situations or problematic
areas?
 How does leadership demonstrate
the organization’s culture and safety
values?
 How does the organization measure
culture and safety?
 How does leadership establish
methods to identify areas of risk or
access employee suggestions for
change?
 How are changes implemented?
20 What are the barriers to Describe specific barriers to effective

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communication of communication among caregivers that have
potential risk factors? been identified by the organization. For
example, residual intimidation or reluctance
to report co-worker activity.
Identify the measures being taken to break
down barriers (e.g. use of SBAR). If there are
no barriers to communication discuss how
this is known.
21 How is the prevention of Describe the organization’s adverse outcome
adverse outcomes procedures and how leadership plays a role
communicated as a high within those procedures.
priority?
22 How can orientation and Describe how orientation and ongoing
in-service training be education needs of the staff are evaluated and
revised to reduce the risk discuss its relevance to event. (e.g.
of such events in the competencies, critical thinking skills, use of
future? simulation labs, evidence based practice, etc.)

23 Was available Examples may include, but are not limited to:
technology used as  CT scanning equipment
intended?  Electronic charting
 Medication delivery system
 Tele-radiology services
24 How might technology Describe any future plans for implementation
be introduced or or redesign. Describe the ideal technology
redesigned to reduce risk system that can help mitigate potential
in the future? adverse events in the future.

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Action Plan Organization Plan of Action Position/Title Method: Policy,

Risk Reduction Strategies Responsible Party Education, Audit,
Observation &
Implementation
For each of the findings identified in Action Item #1:
the analysis as needing an action,
indicate the planned action expected,
implementation date and associated
measure of effectiveness. OR. …
If after consideration of such a Action Item #2:
finding, a decision is made not to
implement an associated risk
reduction strategy, indicate the
rationale for not taking action at this
time.
Check to be sure that the selected Action Item #3:
measure will provide data that will
permit assessment of the
effectiveness of the action.
Consider whether pilot testing of a Action Item #4:
planned improvement should be
conducted.

Improvements to reduce risk should Action Item #5:

ultimately be implemented in all
areas where applicable, not just
where the event occurred. Identify
where the improvements will be
implemented.
Action Item #6:

Action Item #7:

Action Item #8:

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Bibliography: Cite all books and journal articles that were considered in developing this root cause analysis and action plan.

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