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FRAMEWORK FOR ROOT CAUSE ANALYSIS AND CORRECTIVE ACTIONS*
The Joint Commission’s Framework for Root Cause Analysis and Action Plan provides an example of a comprehensive systematic
analysis. The framework and its 24 analysis questions are intended to provide a template for analyzing an event and an aid in organizing
the steps and information in a root cause analysis.
An organization can use this template to conduct a root cause analysis or even as a worksheet in preparation of submitting an analysis
through the online form on its Joint Commission Connect™ extranet site. Fully consider all possibilities and questions in seeking “root
cause(s)” and opportunities for corrective actions. Be sure to enter a response in the “Analysis Findings” column for each item.
Unexpected findings may emerge during the course of the analysis, or there may be some questions that do not apply in every situation.
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.” “Corrective Actions” should be
developed for every identified root cause.
While the online form provides drop-down menus for many of the form’s cells, the options for these columns are provided here in the
following tables:
The following are in the Root Cause Analysis section:
Root Cause Types: Table A-1 (column 1)
Causal Factors/Root Cause Details: Table A-1 (column 2)
In the Corrective Actions section, the following are added:
Action Strength: Table A-2
Measure of Success: Table A-3
Sample Size: Table A-4
*Disclaimer: The framework found on Joint Commission Connect™ will show the most current iteration of this form.
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EVENT DESCRIPTION
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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ROOT CAUSE ANALYSIS - QUESTIONS
#
Analysis
Questions
Analysis
Findings
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
1
What was the
intended process
flow?
by the policy, procedure, protocol, or
guidelines in effect at the time of the
event. You may need to include multiple
processes.
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
: The process steps as they occurred in
the event will be entered in the next
2
Were there any
steps in the
process that did
not occur as
intended?
intended processes listed in Analysis
Question #1 above.
3
What human
factors were
relevant to the
outcome?
factors that contributed to the event.
Examples may include, but are not limited
to:
•
Boredom
•
Failure to follow established
Page 4 of 18
#
Analysis
Questions
Analysis
Findings
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
•
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
performance
affect the
outcome?
devices used in the course of patient care,
including automated external defibrillator
(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
5
What controllable
environmental
organization’s control affected the
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#
Analysis
Questions
Analysis
Findings
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
factors affected
the outcome?
not limited to:
•
Overhead paging that cannot be
heard in physician offices
•
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
6
What
uncontrollable
external factors
influenced the
outcome?
organization cannot change that
contributed to a breakdown in the
internal process, for example natural
7
Were there any
other factors that
directly influenced
this outcome?
8
What are the
other areas in the
health care
organization
where this could
happen?
exists for similar circumstances. For
example:
• Inpatient surgery/outpatient surgery
• 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
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#
Analysis
Questions
Analysis
Findings
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
9
Was staff properly
qualified and
currently
competent for
their
responsibilities?
all staff and providers involved in the
event. Comment on the processes in
place to ensure staff is competent and
qualified. Examples 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
10
How did actual
staffing compare
with ideal level?
staffing ratios along with unit census at
the 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 dealing with
staffing
contingencies?
care organization does during a staffing
crisis, such as call-ins, bad weather, or
increased patient acuity. Describe the
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#
Analysis
Questions
Analysis
Findings
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
alternative staffing. Examples may
include, but are not limited to:
• Agency nurses
• Cross training
• Float pool
• Mandatory overtime
•
12
Were such
contingencies a
factor in this
event?
their orientation to the area, verification
of competency, and environmental
13
Did staff
performance
during the event
meet
expectations?
expected within or outside of the
processes. To what 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 the
necessary
information
available when
needed?
Accurate?
Complete?
completed, shared, and accessed by
members of the treatment team, to
include providers, according to the
organizational processes. Identify the
information systems used during patient
care. Discuss to what extent the available
patient information (e.g., radiology
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#
Analysis
Questions
Analysis
Findings
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
Unambiguous?
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 is
communication
among
participants
adequate?
communication should include evaluation
of verbal, written, electronic
communication or the lack thereof.
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
16
Was this the
appropriate
physical
environment for
the processes
being carried out?
manage the patient care environment.
This response may correlate to the
response in Question #6 on a more
global scale. 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
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#
Analysis
Questions
Analysis
Findings
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
• Alarm audibility testing
• Evaluation of egress points
• Patient acuity level and setting of
care managed across the continuum
• Preparation of medication outside of
17
What systems are
in place to identify
environmental
risks?
Does the current environment meet
codes, specifications, regulations? Does
staff know how to report environmental
risks? Was there an environmental risk
involved in the event that was not
18
What emergency
and failure-mode
responses have
been planned and
tested?
due to an actual emergency or failure
mode response in connection to the
event. 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
•
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#
Analysis
Questions
Analysis
Findings
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
• Power loss
19
How does the
organization’s
culture support
risk reduction?
change, suggestions, and warnings from
staff 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 address
disruptive behavior?
• 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
communication of
potential risk
factors?
communication among caregivers that
have 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
21
How does
leadership address
the continuum of
patient safety
events, including
accountability for implementing measures
to reduce risk for patient harm? Has
leadership provided for required
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#
Analysis
Questions
Analysis
Findings
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
close calls,
adverse events,
and unsafe,
hazardous
conditions?
from any analysis following reported
risks?
22
How can
orientation and
in-service training
be improved?
education needs of the staff are evaluated
and discuss its relevance to event. (e.g.,
competencies, critical thinking skills, use
of simulation labs, evidence based
practice, etc.)
23
Was available
technology used
as intended?
process due to education, training,
competency, impact of human
factors, functionality of equipment,
and so on:
• Was the technology designed to
minimize use errors or easy-to-catch
mistakes?
• Did the technology work well with
the workflow and environment?
• Was the technology used outside of
its specifications?
24
How might
technology be
introduced or
redesigned to
reduce risks in the
future?
implementation or redesign. Describe the
ideal technology system that can help
mitigate potential adverse events in the
future.
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CORRECTIVE ACTIONS
Root Cause
Types
(Table A-1)
Causal
Factors/Roo
t Cause
Details
(Table A-1)
Corrective Actions
Action
Strength
(Table A-2)
Measure of Success
(Numerator /
Denominator) (Table A-
3)
Sample
Size
(Table A-4)
Action Item #1:
Action Item #2:
Action Item #3:
Action Item #4:
Action Item #5:
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.
Page 14 of 18
TABLE A-1. ROOT CAUSES
Root Cause Types
Causal Factors / Root Cause Details
Communication
factors
• Communication breakdowns between and among teams, staff, and providers
• Communication during handoff, transition of care
• Language or literacy
• Availability of information
• Misinterpretation of information
•
Presentation of information
Environmental
factors
• Noise, lighting, flooring condition, etc.
• Space availability, design, locations, storage
•
Maintenance, housekeeping
Equipment/device/
supply/
healthcare IT factors
• Equipment, device, or product supplies problems or availability
• Health information technology issues such as display/interface issues (including display of information),
system interoperability
• Availability of information
• Malfunction, incorrect selection, misconnection
• Labeling instructions, missing
• Alarms silenced, disabled, overridden
Task/process
factors
• Lack of process redundancies, interruptions, or lack of decision support
• Lack of error recovery
• Workflow inefficient or complex
Staff performance
factors
• Fatigue, inattention, distraction or workload
• Staff knowledge deficit or competency
• Criminal or intentionally unsafe act
Team factors
• Speaking up, disruptive behavior, lack of shared mental model
• Lack of empowerment
•
Failure to engage patient
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Management/
supervisory/
workforce factors
• Disruptive or intimidating behaviors
• Staff training
• Appropriate rules/policies/procedure or lack thereof
• Failure to provide appropriate staffing or correct a known problem
• Failure to provide necessary information
Organizational
culture/leadership
• Organizational-level failure to correct a known problem and/or provide resource support including
staffing
• Workplace climate/institutional culture
•
Leadership commitment to patient safety
Adapted from: Department of Defense, Patient Safety Program. PSR Contributing Factors List – Cognitive Aid, Version 2.0. May
2013.
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TABLE A-2. ACTION STRENGTH
Action Strength
Action Category
Example
Stronger
Actions
(These tasks
require less
reliance
on humans
to remember to
perform the task
correctly)
Architectural/physical plant
changes
Replace revolving doors at the main patient entrance into the building with powered
sliding or swinging doors to reduce patient falls.
New devices with usability
testing
Perform heuristic tests of outpatient blood glucose meters and test strips and select
the most appropriate for the patient population being served.
Engineering control (forcing
function)
Eliminate the use of universal adaptors and peripheral devices for medical
equipment and use tubing/fittings that can only be connected the correct way (e.g.,
IV tubing and connectors that cannot physically be connected to sequential
compression devices [SCDs]).
Simplify process
Remove unnecessary steps in a process.
Standardize on equipment
or process
Standardize the make and model of medication pumps used throughout the
institution. Use bar coding for medication administration.
Tangible involvement by
leadership
Participate in unit patient safety evaluations and interact with staff; support the
RCA
2
process (root cause analysis and action); purchase needed equipment; ensure
staffing and workload are balanced.
Intermediate
Actions
Redundancy
Use two registered nurses to independently calculate high-risk medication dosages.
Increase in staffing/decrease
in workload
Make float staff available to assist when workloads peak during the day.
Software enhancements,
modifications
Use computer alerts for drug–drug interactions.
Eliminate/reduce
distractions
Provide quiet rooms for programming patient-controlled analgesia (PCA) pumps;
remove distractions for nurses when programming medication pumps.
Education using simulation-
based training, with periodic
refresher sessions and
observations
Conduct patient handoffs in a simulation lab/environment, with after-action
critiques and debriefing.
Checklist/cognitive aids
Use pre-induction and pre-incision checklists in operating rooms. Use a checklist
when reprocessing flexible fiber optic endoscopes.
Eliminate look- and sound-
alikes
Do not store look-alikes next to one another in the unit medication room.
Standardized communication
Use read-back for all critical lab values. Use read-back or repeat-back for all verbal
Page 17 of 18
tools
medication orders. Use a standardized patient handoff format.
Enhanced documentation,
communication
Highlight medication name and dose on IV bags.
Weaker Actions
(These tasks rely
more on
humans to
remember
to perform the
task correctly)
Double checks
One person calculates dosage, another person reviews their calculation.
Warnings
Add audible alarms or caution labels.
New procedure/
memorandum/policy
Remember to check IV sites every 2 hours.
Training
Demonstrate correct usage of hard-to-use medical equipment.
Reference: Action Hierarchy levels and categories are based on Root Cause Analysis Tools, VA National Center for Patient Safety,
http://www.patientsafety.va.gov/docs/joe/rca_tools_2_15.pdf. Examples are provided here.
Source: National Patient Safety Foundation. RCA
2
Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient
Safety Foundation; 2015. Reproduced with permission.
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TABLE A-3. MEASURE OF SUCCESS
Fraction Part
Defined
Identified
Example
Numerator
The number of
events being
measured
Ask a specific
question—what are
you measuring?
Falls that resulted in hip fractures
in diabetic patients over 70 years of
age
Denominator
All the opportunities
in which the event
could have occurred
Identify the patient
population from
which to collect the
information.
The number of diabetic patients on
a unit who are older than 70 years
of age
TABLE A-4. SAMPLE SIZE*
*The sampling methodology was determined using quality assurance sampling methods which determines the sample size needed to be able
to say from a sample of cases that the “defect” rate is less than a specified amount (here we used 10%) with 95% confidence if no
“defects” are found in the sample.
Population Size
Sample
Fewer than 30 cases
100% of cases
30 to 100 cases
30 cases
101 to 500 cases
50 cases
Greater than 500 cases
70 cases