Borang RCA 1 Root Cause Analysis

CONFIDENTIAL

FORM RCA 1

Root Cause Analysis
Incident Reporting & Learning System
CASE OF

:

DATE OF INCIDENT
INCIDENT CODE

: ( DD / MM / YYYY )

: __________________

INTRODUCTION :
BRIEF description of Incident :

Team assigned for investigation :

Name

Designation
Team Leader
Team Members

1.
2.
3.
4.
5.

ANALYSIS & FINDINGS :

1

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FORM RCA 1

Sequence of event
Date

Time
(24 h)

Location

Event description

Eg:
1.1.11

1300H

A&E

Procedure X was done on
the patient

Key person
involved &
designation
Dr. AB (HO)
(Don’t state
real name)

Comments
Not supervised by
senior

2

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FORM RCA 1

FISH BONE DIAGRAM (REFER TO LONDON PROTOCOL FOR CATEGORISATION)

MANAGEMENT & ORGANISATIONAL

FACTORS

TEAM FACTORS
1.

TASK & TECHNOLOGY FACTORS
1.

1.

INCIDENT/ ISSUE

EXTERNAL FACTORS
1.

WORK/CARE ENVIROMENT
FACTORS

INDIVIDUAL STAFF FACTORS
1.

PATIENT FACTORS
1.

1.

* If not included in the London protocol, kindly place the contributing factor in the most suitable category provided.
EVENT CAUSAL FACTOR CHART (OPTION 1)

3

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FORM RCA 1

EVENT 1

EVENT 2

EVENT 3

EVENT 4

[EVENT]

[EVENT]

[EVENT]

[EVENT]

[DATE & TIME]

[DATE & TIME]

[DATE & TIME]

[DATE & TIME]

CAUSED BY

- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]

CAUSED BY
- [ EXPLAINATION ]

CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]

CAUSED BY
- [ EXPLAINATION ]

EVENT

CAUSAL
FACTOR CHART
CAUSED
BY
CAUSED BY

CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]

CAUSED BY
- [ EXPLAINATION ]

CONTINUE ON
THE NEXT PAGE /
FINAL INCIDENT
OR ISSUE

CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]
CAUSED BY
- [ EXPLAINATION ]

CAUSED BY
- [ EXPLAINATION ]

CAUSED BY

CAUSED BY

- [ EXPLAINATION ]
EVENT 5
[EVENT]CAUSED BY

- [ EXPLAINATION ]

EVENT 6
[EVENT]CAUSED BY

- [ EXPLAINATION ]
EVENT 7
CAUSED BY
[EVENT]

- [ EXPLAINATION ]
EVENT 8
CAUSED BY
[EVENT]

& TIME] ]
- [DATE
[ EXPLAINATION

& TIME]
-[DATE
[ EXPLAINATION

]

- [DATE
[ EXPLAINATION
& TIME] ]

- [DATE
[ EXPLAINATION
& TIME] ]

EVENT OR ISSUES

4

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FORM RCA 1

5

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FORM RCA 1

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 :

6

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FORM RCA 1

Recommendations
1. Root cause(s) identified.
Use the following coding :
Code
1
2
3
4
5
6
7
8

Factor
Patient Factor
Task and technology factor
Staff factor
Team factor
Work & care environment factor
Management and organisation factor
External factor
Other ( Unspecified )

CATEGORY OF
FACTOR
Examples :
4

Lack of communication between teams ( Surgical & Medical ) that reviewed the patient

6

Not enough staf

ROOT CAUSE

2. ACTION PLAN/ RISK REDUCTION STRATEGIES CATEGORY

7

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CODE

FORM RCA 1

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

2

Substitution

-

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.
-

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

4

Administrative control

5.

Personal protective equipment

6.

Others

-

Implementation of checklist & safe work practices
Improvement of staf rotation / shift
Develop new policy, guideline or S.O.P
Education / CME / CNE
Human resource
Preventive maintained

Usage of protective equipment
Not included in any categories specified

Action plan table

8

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No
.

Root Cause

FORM RCA 1
Action
Code.

Action Plan

Person responsible

Due
date

Revie
w
Date

Outcome
Measures

Completi
on Date

Example :

Eg.
1

Absence of policy &
education for care of
patient with suicidal
risk

4

- Development of policy of care
of patient with suicidal risk in
collaboration with the
psychiatric dept.
- Education on care of patient
with suicidal risk.

Head Of Department /
Specialist

1.1.1
1

1.3.11

Availability of
policy
CME/CNE done

27.2.11
10.1.11

9

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FORM RCA 1

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

:

10