CONFIDENTIAL FORM RCA 1

Root Cause Analysis

Incident Reporting & Learning System

CASE OF :

DATE OF INCIDENT : ( DD / MM / YYYY )

INCIDENT CODE : __________________

INTRODUCTION :

BRIEF description of Incident :

Team assigned for investigation :

Name Designation
Team Leader

Team Members
1.
2.
3.
4.
5.

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ANALYSIS & FINDINGS :

Sequence of event
Key person
Time
Date Location Event description involved & Comments
(24 h)
designation
Dr. AB (HO)
Eg: Procedure X was done on Not supervised by
1300H A&E (Dont state
1.1.11 the patient senior
real name)

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FISH BONE DIAGRAM (REFER TO LONDON PROTOCOL FOR CATEGORISATION)

MANAGEMENT & TEAM FACTORS TASK & TECHNOLOGY

ORGANISATIONAL FACTORS FACTORS
1.
1. 1.

INCIDENT/ ISSUE

EXTERNAL FACTORS WORK/CARE ENVIROMENT INDIVIDUAL STAFF FACTORS PATIENT FACTORS

FACTORS
1. 1. 1.
1.

* If not included in the London protocol, kindly place the contributing factor in the most suitable category provided.

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EVENT CAUSAL FACTOR CHART (OPTION 1)

EVENT 1 EVENT 2 EVENT 3 EVENT 4

[EVENT] [EVENT] CONTINUE ON THE
[EVENT] [EVENT]
NEXT PAGE / FINAL
[DATE & TIME] [DATE & TIME] [DATE & TIME] [DATE & TIME] INCIDENT OR ISSUE

CAUSED BY CAUSED BY CAUSED BY CAUSED BY

- [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ]

CAUSED BY CAUSED BY CAUSED BY CAUSED BY

- [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ]

CAUSED BY CAUSED BY CAUSED BY CAUSED BY

- [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ]

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EVENT CAUSAL FACTOR CHART

EVENT 5 EVENT 6 EVENT 7 EVENT 8 EVENT OR ISSUES

[EVENT] [EVENT] [EVENT] [EVENT]
[DATE & TIME] [DATE & TIME] [DATE & TIME] [DATE & TIME]

CAUSED BY CAUSED BY CAUSED BY CAUSED BY

- [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ]

CAUSED BY CAUSED BY CAUSED BY CAUSED BY

- [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ]

CAUSED BY CAUSED BY CAUSED BY CAUSED BY

- [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ] - [ EXPLAINATION ]

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5 WHY METHOD ( OPTION 2)

(Identify problem / issue and ask why for at least 5 times to gain the root cause(s))

PROBLEM / ISSUES

QUESTION : WHY ..

ANSWER :

QUESTION : WHY ..

ANSWER :

QUESTION : WHY ..

ANSWER :

QUESTION : WHY ..

ANSWER :

QUESTION : WHY ..

ANSWER :

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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
ROOT CAUSE
FACTOR
Examples :
4 Lack of communication between teams ( Surgical & Medical ) that reviewed the patient
6 Not enough staff

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2. ACTION PLAN/ RISK REDUCTION STRATEGIES CATEGORY

CODE ACTION PLAN CATEGORY EXPLANATION & EXAMPLES OF ACTION PLAN

Applicable for any action taken where the hazard is removed to prevent the
reoccurrence of incident.

1 Elimination - Removing unnecessary step(s) in procedure or S.O.P

- Removing faulty device / equipment
- Removal of hazardous material

Applicable for any action taken where the hazard is substitute with a less hazardous
material/ procedure.
2 Substitution
- Replacing hazardous equipment with safer equipment.

Applicable for any action taken where technology/ engineering is used to reduce the risk
of incident.
3 Engineering control
- Application of IT system for prescription of medicine to prevent medication error
- Usage of central alarm system for patient on ventilator

Usage of regulations, policies or S.O.P(s) to reduce the risk of incident

- Implementation of checklist & safe work practices

- Improvement of staff rotation / shift
4 Administrative control
- 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

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Action plan table

No. Root Cause Action Action Plan Person responsible Due Review Outcome Measures Completion
Code. date Date Date
Example :
- Development of policy of care
Absence of policy & of patient with suicidal risk in
Availability of policy 27.2.11
Eg. education for care of collaboration with the psychiatric Head Of Department /
4 1.1.11 1.3.11
1 patient with suicidal dept. Specialist
CME/CNE done 10.1.11
risk - Education on care of patient
with suicidal risk.

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RESIDUAL RISK

( Outline residual risk that will exist if risk reduction strategies/ corrective
actions are not taken )

LEARNING POINTS

REPORTED BY :

CHECKED & CORRECTED BY :

DATE :

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