Root Cause Analysis Investigation Report

National Patient Safety Agency

RCA Investigation Report Template - Guidance
The following headings are designed to improve the recording of information currently considered good
practice for investigation reports. These headings will be evaluated over time to confirm or challenge that
understanding.
PLEASE REA - Instruction for use of t!is RCA Report Template
"# etermine t!e level of investigation to $e underta%en
Refer to the NPSAs Three evels of investigation !evel " # $oncise% evel & # $omprehensive% evel '
# (ndependent)* to the NPSASs Triggers for (nvestigation* and to your own organisational policy and
terms of reference.
&# elete all R'(S not re)uired for t!e level of investigation $eing underta%en
The investigation level numbers in the middle column provide a guide to which rows are needed for which
level of investigation. !i.e. for a evel " + $oncise investigation you only need rows which have the
number " in the evel column)
*# (rite your investigation report in t!e rig!t !and column
,elete e-amples !in green)* and refer to summary guidance in the left hand column as you go. .or
detailed guidance refer to the NPSAs /uide to R$A investigation report writing.
(f an investigation produces no information against a heading* add an e-planation on why this is the case.
(f issues arise which re0uire a new heading this can be added as a new row
+# 'n completion, delete t!e guidance to produce your final report
,elete all guidance both here and in the template below !i.e. all green and red type* all green
coloured rows and all green coloured columns)
Realign the remaining table containing your own report* so that it fits the whole page.
Save the document with the chosen file name for each individual investigation report.
-uic% reference guide
Level
Type your investigation report in t!is column
Cover page
1rganisation name and 2 or logo
Title or Brief outline of incident
(ncident date
(ncident number
Author!s)
Report date
Page numbers
,ocument version
$omputer .ile Path
& 3 '
Contents page
& 3 '
C'NTENTS
4-ecutive summary
(ncident description and conse0uences
Pre+investigation ris5 assessment
6ac5ground and conte-t
Terms of reference
The investigation team
Scope and level of investigation
(nvestigation type* process and methods used
(nvolvement and support of patient and relatives
(nvolvement and support provided for staff involved
(nformation and evidence gathered
$hronology of events
6lan5 investigation template 7 National Patient Safety Agency 8 9an. &::;
,etection of incident
Notable practice
$are and service delivery problems
$ontributory factors
Root causes
essons learned
Recommendations
Arrangements for shared learning
,istribution list
Appendices
E.ecutive summary
& 3 '
E/EC0TI1E S022AR3
A one page summary of the main report
& 3 '
4rief Incident description
presented succinctly under the following
& 3 ' Incident date5
headings<+
& 3 ' Incident type5
& 3 ' 6ealt!care specialty5
& 3 ' Actual effect on patient and7or service5
& 3 ' Actual severity of t!e incident5
& 3 '
Level of investigation conducted
& 3 '
Involvement and support of t!e patient and7or
relatives
& 3 '
etection of Incident
& 3 '
Care and Service elivery Pro$lems
& 3 '
Contri$utory 8actors
& 3 '
Root Causes
& 3 '
Lessons Learned
& 3 '
Recommendations
& 3 '
Arrangements for S!aring Learning
2ain Report
"* & 3'
2AIN REP'RT
Incident description and
conse)uences
$oncise incident description
"* & 3'
Incident description and conse)uences
E.ample only 9please delete and add your o:n findings;
A lady with asthma sustained brain damage following (=
administration of a drug to which she was 5nown to be allergic.

(ncident date
"* & 3'
(ncident date<
(ncident type
"* & 3'
(ncident type<
>ealthcare speciality involved
"* & 3'
Specialty<
Actual effect on patient and 2 or service
"* & 3'
4ffect on patient<
Actual severity of incident
"* & 3'
Severity level<
Pre-investigation ris%
assessment
Assess the realistic li5elihood and severity
of recurrence* using your organisations
Ris5 ?atri-
& 3 '
Pre-investigation ris% assessment
A
Potential Severity
9"-<;
4
Li%eli!ood of recurrence
at t!at severity 9"-<;
C
Ris% Rating
9C = A . 4;
6lan5 investigation template 7 National Patient Safety Agency 8 9an. &::;
4ac%ground and conte.t to t!e
incident
A brief description of the service type*
service si@e* clinical team* care type*
treatment provided etc.
& 3 '
4ac%ground and conte.t
Terms of reference - 1utline <+
Specific problems to be addressed
Aho commissioned the report
(nvestigation lead and team
Aims* 1bBectives and 1utputs !see
e-amples opposite)
Scope* boundaries and collaborations
Administration arrangements
!accountability* resources* monitoring)
Timescales
& 3 '
Terms of reference
E.ample only 9please amend to $uild your o:n aims;
To establish the facts i.e.<+ :!at happened !the effect)* to
:!om* :!en, :!ere* !o: and :!y !root causes)
To establish whether failings occurred in care or treatment
To loo5 for improvements rather than to apportion blame
To establish how recurrence may be reduced or eliminated
To formulate recommendations and an action plan
To provide a report as a record of the investigation process
To provide a means of sharing learning from the incident

Investigation team
Names* Roles* Cualifications* ,ept.s
& 3 '
T!e investigation team
Scope and level of investigation
State level of investigation
!NPSA +".$oncise% &.$ompre.% '.(ndependent)
,escribe the start and end points
ist services D orgs involved
N6< for evel ' (ndependent (nvestigations
scope could be included under Terms of
Reference
"* & 3'
Scope and level of investigation
Investigation type !i.e. Single 2
Aggregation 2 ?ulti+incident), process,
and met!ods used
/athering information e.g. Interviews
(ncident ?apping e.g. Tabular timeline
(dentifying $are and service delivery
problems e.g. Change analysis
(dentifying contributory factors D root
causes e.g. Fishbones
/enerating solutions e.g. Barrier
analysis
& 3 '
Investigation type, process and met!ods used
Involvement and support of
patient and relatives
e.g. ?eetings to discuss 0uestions the
patient anticipates the investigation will
address and to hear their recollection of
events !anonymised in line with the
patient2relative wishes).
e.g. .amily liaison person appointed*
information given on sources of
independent support.
"* & 3'
Involvement and support of patient and relatives
Involvement and support
provided for staff involved
Refer !anonymously) to involvement of staff
in the investigation* and to formal D
informal support provided to those involved
and not involved in the incident.
& 3 '
Involvement and support provided for staff involved
Information and evidence
& 3 '
Information and evidence gat!ered
6lan5 investigation template 7 National Patient Safety Agency 8 9an. &::;
gat!ered
A summary list of relevant local and
national policy 2 guidance in place at the
time of the incident* and any other data
sources used<+
!(nclude<+Title and date of /uidance*
Policies* ?edical records* interview
records* training schedules* staff rotas*
e0uipment* etc)
E.ample only 9please delete and add your o:n findings;
(nterviews with the four staff on duty + :".:&.:E
(nterviews with patient relatives + :F.:&.:E
A visit to the location of the incident +"G.:&.:E
The patients clinical records
C!ronology of events
.or comple- cases any summary timeline
included in the report should be a summary
"* & 3'
C!ronology of events
See table below

etection of incident
Note at which point in the patients
treatment the error was identified. i.e.
At ris5 assessment of new2changed service
At pre+treatment patient assessment
4rror recognition pre+care2treatment
4rror recognition post+care2treatment
6y ?achine2System24nviron. change2Alarm
6y a $ount2Audit2Cuery2Review
6y $hange in patients condition
"* & 3'
etection of incident
Select from the list on the left
Add additional information
Nota$le practice
Points in the incident or investigation
process where care and2or practice had an
important positive impact and may provide
valuable learning opportunities.
!e.g. 4-emplar practice* involvement of the
patient* staff openness etc)
& 3 '
Nota$le practice
E.ample only 9please delete and add your o:n findings;
Actions ta5en to inform the patient and relatives of the error in
an open and honest way* and to subse0uently involve them in
the R$A process was valued by all and greatly enhanced the
investigation.
Care and service delivery
pro$lems
A themed list of the key problem points.
!Ahere many problems have been
identified the full list should be included in
the appendi-)
"* & 3'
Care and service delivery pro$lems
E.ample only 9please delete and add your o:n findings;
Nurses on the short stay ward routinely failed to complete the
section in the patient notes to highlight the e-istence of 5nown
allergies
Contri$utory factors
A list of significant contributory factors
!where many contributory factors are
identified a full list or fishbone diagrams
should be included in the appendi-)
"* & 3'
Contri$utory factors
E.ample only 9please delete and add your o:n findings;
1ver years numerous assessments for nutrition* pressure
ulcers* falls ris5 etc. had been added* causing short stay wards
to see the completion of all documentation as impossible.
Root causes !numbered)
These are the most fundamental underlying
factors contributing to the incident that can
be addressed. Root causes should be
meaningful* !not sound bites such as
communication failure) and there should be
a clear lin5* by analysis* between root
$AHS4 and 4..4$T on the patient.
"* & 3'
Root causes
E.ample only 9please delete and add your o:n findings;
". Ahen adding or updating patient assessments and care
plans* ris5 assessment of the wider implications of their use
should be conducted and acted upon to reduce the ris5 of
impact on patient safety
Lessons learned !numbered)
Iey safety and practice issues identified
which may not have contributed to this
incident but from which others can learn.
"* & 3'
Lessons learned
E.ample only 9please delete and add your o:n findings;
". A distinction should be made between essential and desirable
documentation in clinical records
6lan5 investigation template 7 National Patient Safety Agency 8 9an. &::;
Recommendations !numbered and
referenced) Recommendations should be
directly lin5ed to root causes and lessons
learned* They should be clear but not
detailed !detail belongs in the action plan).
(t is generally agreed that 5ey
recommendations should be 5ept to a
minimum where ever possible.
"* & 3'
Recommendations
E.ample only 9please delete and add your o:n findings;
". 4nsure allergy records and other priority assessment sheets
are routinely filed prominently for ease of completion
&. 4nsure essential assessment criteria are set as mandatory
fields in new electronic record development
Arrangements for s!ared
learning
,escribe how learning has been or will be
shared with staff and other organisations
!e.g. through bulletins* PSAT2Regional
offices* professional networ5s* NPSA* etc.)
"* & 3'
Arrangements for s!ared learning
E.ample only 9please delete and add your o:n findings;
Share findings with other departments caring for short stay
patients and include them in piloting solutions
Share findings with patient Safety Action Team to identify
opportunities for sharing outside the organisation
istri$ution list
,escribe who !e.g. patients* relatives and
staff involved) will be informed of the
outcome of the investigation and how
& 3 '
istri$ution list
Appendices
(nclude 5ey e-planatory documents. e.g.
Tabular timeline* $ause 3 effect chart*
Ac5nowledgements to patients* family* staff
or e-perts etc.
& 3 '
Appendices
Aut!or5
>o$ Title5
ate5
C!ronology 9timeline; of events
ate ? Time Event
6lan5 investigation template 7 National Patient Safety Agency 8 9an. &::;
6lan5 investigation template 7 National Patient Safety Agency 8 9an. &::;