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Root Cause Analysis (RCA) Samples

Part I: Instructions
Root Cause Analysis Report
Individual Completing Report:
Date of Report:
Problem Statement
The problem statement should be clearly defined, concise, and specific. It should relate to the purpose of the Root Cause
Analysis request (e.g., significant event, failure to achieve goals, etc.). The problem statement will guide the root cause
analysis activities and discussion for identified actions for improvement.
Root Cause Identification
Step 1.
Team
Involved
in RCA
Assemble a team for discussion and completion of root cause analysis exercises. The team should consist of
individuals involved in the process where the problem occurred and may include, as appropriate: Physicians,
Clinicians, Peer Specialists, Administrative Staff, Individuals in Treatment, Leadership (Decision-Makers), and
Quality staff.
Consideration should be given to including the "voice of the customer" whenever possible.
Step 2.
Tools
used for
RCA
Complete structured Root Cause Analysis tools such as the Fishbone Diagram and Five Whys for a systematic
identification of causes.
1. Fishbone Diagram (also known as an Ishikawa Diagram)
1.1. Brainstorm potential causes leading to the problem
1.2. Group potential causes together in an affinity diagram and label the categories
1.3. Place the causes into the fishbone diagram with corresponding categories. Generally, it is best
if teams identify their own categories to ensure no potential causes are overlooked. However,
some teams find that causes end up in one of the following category groupings: (Methods,
Equipment, People, Materials, Measurement, Environment) or (Policies, Procedures, People,
and Plant)
1.4. Identify the top "root causes" leading to the problem
2. Five Whys
The Five Whys activity can be utilized to dig deeper on a root cause identified during the Fishbone
exercise. The exercise starts with this question: Why did this problem occur? The team will answer
this question. Then, the team will ask why did that happen or occur? This will continue until the team
reaches "I don't know." The Five Whys activity can be conducted on more than one cause identified
by the team during the Fishbone exercise.
Step 3.
Identified
Root
Cause(s)
The team will identify the main cause(s) of the problem that need to be addressed. Please list the root causes to
be addresse

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Root Cause Analysis Report
Proposed Plan of Action
The most important aspect of a Root Cause Analysis is to develop a proposed plan of action to reduce the chance that this
problem/event would happen again. When the root cause has been identified, the team should develop a list of solutions to
address the problem and commit to the solutions that will have the most impact. Solutions, or actions, should be immediate
whenever possible. However, it is important to identify and address actions that may take longer as well to ensure that the
problem does not continue to occur. The following table can be used to ensure that actions are identified and addressed
meaningfully:
Area of Concern
(Root Cause) Intervention Target Date Responsible
Person
Monitoring
Mechanism
Learn more about how to conduct a Fishbone Diagram or the Five Whys activity by watching a video on You are not allowed to view links. Register or Login
as part of the Quality Improvement Basics educational series.
Tools and templates for the Affinity Diagram, Fishbone Diagram, and Five Whys can be found at

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Part II: Root Cause Analysis (RCA) Reporting Template
Root Cause Analysis Report
Individual Completing Report:
Date of Report:
Problem Statement
Root Cause Identification
Step 1.
Team
Involved
in RCA
Step 2.
Tools
used for
RCA
Step 3.
Identified
Root
Cause(s)
Proposed Plan of Action
Area of Concern
(Root Cause) Intervention Target Date Responsible
Person
Monitoring
Mechanism

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art III: Example of a Completed RCA Report
Root Cause Analysis Report
Individual Completing Report: Mary Smith, Program Manager
Date of Report: July 1, 2021
Problem Statement
The following problem statement is related to a medication error event that occurred for Patient A:
On Day 15, it was noted that Patient A had not received his bimonthly Olanzapine 150 mg long acting injectable (LAI) on
Day 1 as scheduled. The ordering psychiatrist was notified, and the medication was administered on Day 16.
Root Cause Identification
Step 1.
Team
Involved
in RCA
Psychiatrist
Temporary Nurse
Nursing Supervisor
Manager of Quality
Program Manager
Step 2.
Tools
used for
RCA
An Affinity Diagram and Fishbone Diagram were completed and are embedded in this document.
Step 3.
Identified
Root
Cause(s)
1. Education was not provided to the temporary nurse regarding about the protocol for processing
physician orders for long-acting-injectable (LAI) medications. As a result, nurse did not realize the
medication was due to be given.
2. There was no alert or flag in the electronic health record (EHR) indicating that the medication was
overdue.
3. There was no policy for regularly schedule review of the medication administration record (MAR) by
the clinical team to identify the medication was not given.

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Proposed Plan of Action
Area of Concern
(Root Cause) Intervention Target Date Responsible
Person
Monitoring
Mechanism
Education about
procedures related to
Long Acting
Injectables (LAI) was
not provided as part of
onboarding for
temporary nursing
staff
Update onboarding
education to include
procedures related to
long acting injectables
Train nursing
Supervisors on updates
to onboarding process
Train all current
temporary staff on LAI
procedures
Immediately Program Manager Updated Onboarding
Education Materials
Training Records
Electronic Health
Record Notification
Process
Develop automatic
flag in electronic
health record so that
treatment team (RN
and prescriber) are
made aware that
patient is due for Long
Acting Injectable.
Next month Nursing Supervisor Nursing Supervisor
will attend electronic
health record
workgroup regularly
to facilitate
developing this flag.
No policy related to
review of Medication
Administration
Records (MAR)
Update Medication
Administration policy
to include weekly
review of MAR by
treatment team, and
documentation that
review has occurred.
Train all nursing and
medical staff on
Medication
Administration policy
updates
Next week Program Manager Updated Policy
Training Records
Program manager to
review 5 charts per
week to ensure that
review of MAR was
conducted at least
once weekly

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