Root Cause Analysis Toolkit
For facilities that are new to conducting root cause analysis - and even for those who are more experienced - it can sometimes be difficult to establish a process that runs smoothly, is comfortable for participants, and leads to meaningful, focused discussions of system issues that may have contributed to events. This online RCA toolkit is designed to be a resource for any facility that would like to establish or improve their RCA process. It contains sample policies, position descriptions and agendas, graphic organizers and visual aids, question guides, invitations and groundrules, case studies and other documents that facilities can use to educate their staff, their RCA facilitators, or their leaders about this process. You are welcome to make use of anything in this toolkit, or to adapt it for your own purposes. Where appropriate, please cite the organization that is the source of the tool.
This toolkit will evolve and change over time, as we become aware of new tools and resources that may be helpful. If you have documents or resources that you would like to contribute, please email them to Diane Rydrych at diane.rydrych@state.mn.us.
General Information/Overviews/Tutorials about RCA
● Allina RCA presentation● RCA Process Handout
● RCA North Dakota presentation
● Sentinel Event Process Algorithm
Graphic Organizers/Diagrams
● 5whystool● Cause and Effect Diagram
● Fishbone - Modified template
● Sequence of Events
● Staff Credential Table
Roles/Responsibilities
● Admin Assistant role in scheduling RCA● Area Leadership role in RCA process
● Med Director Pt Safety Role in RCA process
● Patient Safety Analyst role in RCA process
● VP and Chief of Area Involved
● RCA Process Checklist
● RCA Agenda for poster
● Sentinel Event Process Algorithm
● Root Cause Analysis Process
RCA Question Guides/Contributing Factors
● Interviewing Questions Techniques● Leading an RCA Interview
● The Ladder of Interference: Avoid Jumping to Conclusions
● RCA triggering/triage questions for hospitals
● RCA triggering/triage questions for long term care
● Staffing review form for AHE
● RCA Questions
● Clinical Practice Influencing Factors
● Guide to Cognitive Process and Error Proofing
● Joint Commission Minimum RCA Scope for long term care (page 10)
● Joint Commission Minimum RCA Scope for hospitals (page 11-12)
● Falls investigation form for LTC
● RCA Template
● Staff Credential Table
● Contributory Factors Classification Framework (NHS)
Checklists/Templates/Agendas for review process
● RCA Only Template● Allina Critical Event Review template
● RCA Process Checklist
● RCA handout
● RCA Agenda for poster
● RCA Agenda & packet
● Pt Safety Analyst RCA references
● Root Cause Analysis Summary form
● RCA Team Members
● RCA Template
● Root Cause Analysis Process
Invitations & Groundrules
● RCA Invite list● RCA Meeting Invite Template
Corrective Actions/Measurement
● Guide to Cognitive Process and Error Proofing● Hierarchy of Corrective Actions
● Implementation Plan Template
● Measurement guide for adverse events
● Mistake Proofing, intervention hierarchy
● PDSA Worksheet for Testing Change
● RCA Area Audit Results
● RCA Follow Up Action Plan
● Standard Action Plan Template – Rooney Cause Pathway Format
Case Studies/Scenarios
● Case Scenario – Fall● Case Scenario – Fall Root Cause Analysis Summary Form
● Case Scenario – Medication Error
● Case Scenario – Medication Error Root Cause Analysis Summary Form
● Case Scenario – Nursing Home Medication Error
● Case Scenario – Pressure Ulcer
● Case Scenario – Pressure Ulcer Root Cause Analysis Summary Form
