Root Cause Analysis - Questions

#	Analysis Questions	Prompts	Analysis Findings	Root Cause Types (Table A-1)	Causal Factors/Root Cause Details (Table A-1)
1	What was the intended process flow?	List the relevant process steps as defined 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 Note: The process steps as they occurred in the event will be entered in the next question.
2	Were there any steps in the process that did not occur as intended?	Explain in detail any deviation from the intended processes listed in Analysis Question #1 above.
3	What human factors were relevant to the outcome?	Discuss staff-related human performance factors that contributed to the event. Examples may include, but are not limited to: Boredom Failure to follow established policies/procedures Fatigue 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?	Consider all medical equipment and 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 of alarms, displays, and controls
5	What controllable environmental factors affected the outcome?	What environmental factors within the organizations control affected the outcome? Examples may include, but are 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 event.
6	What uncontrollable external factors influenced the outcome?	Identify any factors the health care organization cannot change that contributed to a breakdown in the internal process, for example natural disasters.
7	Were there any other factors that directly influenced this outcome?	List any other factors not yet discussed.
8	What are the other areas in the health care organization where this could happen?	List all other areas in which the potential 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 help drive the scope of your action plan.
9	Was staff properly qualified and currently competent for their responsibilities?	Include information on the following for 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 issues
10	How did actual staffing compare with ideal level?	Include ideal staffing ratios and actual 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 areas staffing ratio, experience level, and skill mix?
11	What is the plan for dealing with staffing contingencies?	Include information on what the health care organization does during a staffing crisis, such as call-ins, bad weather, or increased patient acuity. Describe the health care organizations use of alternative staffing. Examples may include, but are not limited to: Agency nurses Cross training Float pool Mandatory overtime PRN pool
12	Were such contingencies a factor in this event?	If alternative staff were used, describe their orientation to the area, verification of competency, and environmental familiarity.
13	Did staff performance during the event meet expectations?	Describe whether staff performed as 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.