# Root Cause Analysis and Action Report: [Event reference]

> Report template for a systems-focused review of a serious patient
> safety event or close call, from risk-based prioritisation through
> causal statements to ranked corrective actions with measures. The
> process and tools follow the RCA2 approach (Root Cause Analysis and
> Action) described in *RCA2: Improving Root Cause Analyses and Actions
> to Prevent Harm* (National Patient Safety Foundation, 2015, version 2
> January 2016, now hosted by the Institute for Healthcare Improvement),
> written in original words for this collection. The worked example is a
> fictional inpatient fall. Replace every `[bracketed]` value and every
> row marked *Example*. This is a documentation format, not legal or
> medical advice; check the current official text of any policy or
> regulation that applies to you and involve qualified professionals.

<!--
Guidance: How to use this template
- The review looks for system vulnerabilities, not for someone to blame.
  If the event may involve a criminal act, abuse, impairment or a
  deliberately unsafe act, stop and refer it (section 3).
- Keep the clock: score the event with your risk matrix within 72 hours,
  start the review within 72 hours of deciding it is needed (RCA2
  recommendation 5), and aim to finish within 30 to 45 days, the period
  RCA2 reports several organisations recommend.
- Work in this order: what happened (section 6), why it happened
  (sections 7 and 8), what will stop it happening again (section 9), how
  you will know (section 10).
- Use the same IDs throughout: chronology steps T01, contributing
  factors CF-01, causal statements CS-01, actions ACT-01 and measures
  MEA-01, numbered in sequence.
- Store the report under legal privilege or protected status only as
  your organisation's counsel advises; rules differ by country and state.
- No patient names or record numbers in the body. Use a case reference.
-->

## Document control

<!-- Guidance: Record who convened the review and the key dates, because RCA2 sets timing expectations and leadership must sign off the actions. -->

| Field | Value |
|---|---|
| Document ID | [RCA-2026-012] |
| Event reference | [Incident system reference] |
| Event date | YYYY-MM-DD |
| Date review required (prioritisation done) | YYYY-MM-DD |
| Convening authority | [@chief-medical-officer or delegate] |
| Review lead (facilitator) | [@patient-safety-lead] |
| Version | [0.4] |
| Status | [Draft / Leadership review / Approved / Closed] |
| Owner | [@review-lead] |
| Approvers | [@ceo-or-delegate], [@convening-authority] |
| Target completion | [Event date + 45 days] |
| Last updated | YYYY-MM-DD |
| Classification | [Confidential: patient safety review] |

### Approvals

| Role | Name | Decision | Date |
|---|---|---|---|
| Review lead | [@name] | [Submitted] | YYYY-MM-DD |
| Convening authority | [@name] | [Approved] | YYYY-MM-DD |
| Chief executive or delegate (actions and risk acceptance) | [@name] | [Approved with comments] | YYYY-MM-DD |

## Revision history

<!-- Guidance: One row per draft shared outside the team. Note when actions are added or downgraded, so the action hierarchy decisions are traceable. -->

| Version | Date | Author | Change summary |
|---|---|---|---|
| 0.1 | YYYY-MM-DD | [@name] | Event summary, prioritisation and charter |
| 0.2 | YYYY-MM-DD | [@name] | *Example:* Chronology and flow diagram after interviews |
| 0.3 | YYYY-MM-DD | [@name] | *Example:* Causal statements CS-01 to CS-04 and actions |
| 0.4 | YYYY-MM-DD | [@name] | *Example:* Measures added; leadership comments addressed |

## Contents

<!-- Guidance: Keep in sync with the headings below. -->

1. [Event summary and immediate actions](#1-event-summary-and-immediate-actions)
2. [Risk-based prioritisation](#2-risk-based-prioritisation)
3. [Scope and blameworthy-event screen](#3-scope-and-blameworthy-event-screen)
4. [Review team and charter](#4-review-team-and-charter)
5. [Information gathered](#5-information-gathered)
6. [What happened: chronology and flow diagram](#6-what-happened-chronology-and-flow-diagram)
7. [Why it happened: contributing factors](#7-why-it-happened-contributing-factors)
8. [Causal statements](#8-causal-statements)
9. [Corrective actions and the action hierarchy](#9-corrective-actions-and-the-action-hierarchy)
10. [Measures of implementation and effectiveness](#10-measures-of-implementation-and-effectiveness)
11. [Feedback to patient, family and staff](#11-feedback-to-patient-family-and-staff)
12. [Leadership review and risk acceptance](#12-leadership-review-and-risk-acceptance)
13. [External reporting and regulatory context](#13-external-reporting-and-regulatory-context)
14. [Follow-up and closure](#14-follow-up-and-closure)
15. [Glossary and references](#15-glossary-and-references)

## 1. Event summary and immediate actions

<!-- Guidance: Two short paragraphs of fact: what happened, to whom (de-identified), where, when and the harm. Then list what was done straight away to care for the patient, make the area safe and preserve evidence. No analysis or judgement here. -->

**Event summary.** [Describe the event or close call in neutral,
factual language: type of event, location, time, outcome for the
patient.]

*Example:* A patient in their 80s, admitted to Ward 4 (adult medicine,
fictional Halvermoor District Hospital) with a chest infection, was
found on the floor beside the bed at 02:40 on day 0. An X-ray later that
morning showed a hip fracture, which was repaired surgically on day 1.
The patient had been assessed as at high risk of falls on admission.

| Immediate action | Done by | Time | Status |
|---|---|---|---|
| Patient assessed, treated and escalated to the on-call doctor *(Example)* | Nurse in charge | Day 0 02:45 | Done |
| Patient and family informed of the event (initial disclosure) *(Example)* | Ward consultant | Day 0 10:30 | Done |
| Bed, sensor mat and call bell set aside and labelled for inspection *(Example)* | Nurse in charge | Day 0 03:30 | Done |
| Incident reported in the incident system *(Example)* | Nurse in charge | Day 0 02:55 | Done |
| Similar risks on the ward checked (other high-risk patients reviewed) *(Example)* | Ward manager | Day 0 09:00 | Done |

## 2. Risk-based prioritisation

<!-- Guidance: Score the event with your organisation's approved risk matrix within 72 hours. RCA2 gives the US Veterans Health Administration Safety Assessment Code (SAC) matrix as an example. For a close call, score the reasonable worst case. One named person applies the matrix, for consistency. -->

RCA2 recommends a transparent, formal, risk-based system to decide
which adverse events, close calls and system vulnerabilities need a full
review. The table reproduces the structure of the Safety Assessment Code
(SAC) matrix of the US Veterans Health Administration (a US government
work, as reproduced in RCA2 appendix 1). A score of 3 is the highest
priority, 2 intermediate and 1 the lowest. Your organisation may use a
different matrix; record the one you used.

| Probability (rows) by severity (columns) | Catastrophic | Major | Moderate | Minor |
|---|---|---|---|---|
| Frequent (may happen several times in 1 year) | 3 | 3 | 2 | 1 |
| Occasional (may happen several times in 1 to 2 years) | 3 | 2 | 1 | 1 |
| Uncommon (may happen sometime in 2 to 5 years) | 3 | 2 | 1 | 1 |
| Remote (may happen sometime in 5 to 30 years) | 3 | 2 | 1 | 1 |

| Field | Value |
|---|---|
| Matrix used | [SAC matrix / organisational risk matrix, document ID] |
| Severity (actual, or worst case for a close call) | [Category and reason] |
| Probability | [Category and data used] |
| Score | [1 / 2 / 3] |
| Decision | [Full RCA2 review / aggregated review / local review] |
| Scored by and when | [@name, YYYY-MM-DD hh:mm, hours since event] |

*Example:* Severity Major (surgical intervention required). Probability
Frequent: the ward recorded three falls with injury in the previous 12
months. Score 3. Full RCA2 review required; scored by the patient
safety lead on day 1 at 11:00, about 32 hours after the event.

## 3. Scope and blameworthy-event screen

<!-- Guidance: RCA2 asks each organisation to define blameworthy events in advance and handle them outside the safety review. If the team finds such a sign at any point, it stops and refers to the convening authority. Referral does not end the learning; it moves responsibility. -->

**Scope.** [State what the review covers and what it does not: the
event, the time window, the departments and processes involved.]

*Example:* From the decision to admit to Ward 4 (day -3) to the
transfer to theatre (day 1). Includes falls risk assessment, the
overnight observation process, equipment and staffing. Excludes the
surgical care after transfer, which had no reported concerns.

| Screen question | Answer | Notes |
|---|---|---|
| Any sign of a criminal act? | [Yes / No] | |
| Any sign of patient abuse? | [Yes / No] | |
| Any sign of alcohol or substance impairment of a provider? | [Yes / No] | |
| Any sign of an act your policy defines as intentionally unsafe? | [Yes / No] | |
| If any "Yes": referred to convening authority on | [YYYY-MM-DD] | [Reference] |

## 4. Review team and charter

<!-- Guidance: RCA2 suggests 4 to 6 members: process experts and people from different levels of the organisation, and consideration of a patient representative unrelated to the event. People involved in the event are interviewed, not appointed. Give members protected time. -->

| Role on team | Name | Department | Involved in event? |
|---|---|---|---|
| Facilitator (RCA2 trained) | [@name] | Patient safety | No |
| Subject matter expert *(Example)* | [@name] | Physiotherapy (falls lead) | No |
| Front-line nurse from another ward *(Example)* | [@name] | Ward 7 | No |
| Doctor *(Example)* | [@name] | Geriatric medicine | No |
| Patient representative unrelated to the event *(Example)* | [Name] | Patient partner programme | No |
| Estates or medical equipment engineer (as needed) *(Example)* | [@name] | Clinical engineering | No |

**Charter.**

| Item | Value |
|---|---|
| Question to answer | [What happened, why, and what will reduce the risk of recurrence?] |
| Meetings | [Number planned; RCA2 notes meetings are typically 1.5 to 2 hours] |
| Protected time agreed with line managers | [Yes / No] |
| Deadline for report to convening authority | [YYYY-MM-DD, within 30 to 45 days of the event] |

## 5. Information gathered

<!-- Guidance: List every source so a reader can see the review was thorough. Interview people one at a time, in a private setting, as soon as possible. Visit the site and look at equipment at the same time of day as the event if you can. -->

| Source type | Detail *(Example)* | Date collected |
|---|---|---|
| Interviews | Night nurse, healthcare assistant, nurse in charge, on-call doctor, patient's daughter | Days 3 to 8 |
| Site visit | Ward 4 bay 2 at 02:30, lighting and call bell reach checked | Day 6 |
| Equipment inspection | Bed and sensor mat checked by clinical engineering | Day 4 |
| Records | Admission falls assessment, observation chart, care plan, staffing roster | Day 2 |
| Policies | Falls prevention policy [ID], enhanced observation procedure [ID] | Day 2 |
| Data | Ward falls data for 12 months; staffing fill rates for the month | Day 5 |

## 6. What happened: chronology and flow diagram

<!-- Guidance: Build the chronology from all sources, then draw the flow diagram of what actually happened. Mark where the actual process differed from the expected process. Facts only; analysis comes in section 7. -->

| Step | Time | What happened | Source | Differs from expected? |
|---|---|---|---|---|
| T01 *(Example)* | Day -3 16:00 | Admitted to Ward 4; falls risk assessment completed: high risk | Assessment form | No |
| T02 *(Example)* | Day -3 17:00 | Care plan lists sensor mat and low bed; low bed not available on ward | Care plan, interview | Yes: no low bed |
| T03 *(Example)* | Day -1 14:00 | Bed moved for cleaning; sensor mat unplugged and not reconnected (found at inspection on day 4) | Interview, inspection | Yes |
| T04 *(Example)* | Day -1 22:00 | Night shift: one registered nurse absent, not replaced; 2 staff for 14 patients | Roster | Yes: below planned staffing |
| T05 *(Example)* | Day 0 02:30 | Healthcare assistant attending another patient in bay 4 | Interview | No |
| T06 *(Example)* | Day 0 02:40 | Patient found on floor; reports trying to reach the toilet | Interview, incident report | Not applicable |

```mermaid
flowchart TD
  T01["T01 Admitted, high falls risk"] --> T02["T02 Care plan: low bed and sensor mat"]
  T02 --> D1{"Low bed available?"}
  D1 -- "No" --> G1["Standard bed used"]
  D1 -- "Yes" --> B1["Low bed fitted"]
  G1 --> T03["T03 Sensor mat unplugged after bed moved"]
  B1 --> T03
  T03 --> T04["T04 Night staffing 2 for 14 patients"]
  T04 --> T05["T05 Staff attending bay 4"]
  T05 --> T06["T06 Patient gets up alone, falls"]
```

The diagram shows the actual path (left branch) and the expected
alternative (right branch). In the example, the low bed was unavailable
and the sensor mat had been unplugged before the night of the event.

## 7. Why it happened: contributing factors

<!-- Guidance: Ask "why" at each point where the actual process differed from the expected one. Use the RCA2 triggering question categories (communication, training, fatigue and scheduling, environment and equipment, rules, policies and procedures, barriers) so the team does not stop at the first answer. Group findings in a cause and effect diagram. -->

| ID | Category | Contributing factor *(Example)* | Linked steps |
|---|---|---|---|
| CF-01 | Equipment | The ward has 2 low beds for 28 patients; requests to the equipment library take a median of [n] hours | T02 |
| CF-02 | Equipment and process | The sensor mat plugs into a wall socket that is unplugged when beds are moved; there is no alert when the mat is disconnected | T03 |
| CF-03 | Staffing | Unfilled night shifts are not escalated if the gap is reported after 20:00 | T04 |
| CF-04 | Environment | The toilet in bay 2 is 9 metres from bed 2 and the night lighting does not reach the doorway | T06 |
| CF-05 | Communication | The patient was not told that staff would help at night and believed they should not ring the bell | T06 |

```mermaid
flowchart LR
  EVT["Fall with hip fracture, Ward 4"]
  EQ["Equipment"] --> EVT
  ST["Staffing"] --> EVT
  EN["Environment"] --> EVT
  CO["Communication"] --> EVT
  CF1["CF-01 Too few low beds"] --> EQ
  CF2["CF-02 Mat disconnection not alarmed"] --> EQ
  CF3["CF-03 Night gaps not escalated after 20:00"] --> ST
  CF4["CF-04 Long dark route to toilet"] --> EN
  CF5["CF-05 Patient unsure about calling for help"] --> CO
```

## 8. Causal statements

<!-- Guidance: Write each causal statement as cause, effect and event: "this led to that, which increased the likelihood of the event". Check every statement against the five rules of causation below before you write actions. -->

RCA2 (appendix 6) uses five rules of causation. In short: show the cause
and effect link; use specific descriptions instead of vague negative
words such as "poor" or "inadequate"; trace every human error back to
its preceding cause; treat a procedure violation as a symptom with its
own cause, not as a root cause; and count a failure to act as causal
only when there was a pre-existing duty to act.

| ID | Causal statement *(Example)* | From | Rules check |
|---|---|---|---|
| CS-01 | Ward 4 has 2 low beds for 28 patients and the equipment library has no out-of-hours delivery, so high-risk patients admitted in the afternoon often sleep in a standard-height bed, which increases the likelihood of injury when they get up alone at night | CF-01 | 1 to 5 met |
| CS-02 | The sensor mat depends on a wall socket that is unplugged whenever the bed is moved and gives no alarm when disconnected, so a disconnected mat is not noticed, which increases the likelihood that staff are not alerted when a high-risk patient gets up | CF-02 | 1 to 5 met |
| CS-03 | Night staffing gaps reported after 20:00 go to a bleep holder who has no authority to move staff, so the shift runs with 2 staff for 14 patients, which increases the likelihood that a high-risk patient gets up without help | CF-03 | 1 to 5 met |
| CS-04 | The bedside information for patients does not explain night help and the call bell is not demonstrated on admission, so patients may avoid ringing at night, which increases the likelihood that they walk to the toilet alone | CF-05 | 1 to 5 met |

CF-04 (route to the toilet) was judged a contributing condition rather
than a cause by itself and is addressed in ACT-05 as a supporting action.

## 9. Corrective actions and the action hierarchy

<!-- Guidance: Aim for at least one stronger or intermediate action per review (RCA2). Training and new policies are weaker actions: useful to set expectations, unlikely to be enough alone. Do not self-censor: recommend the most effective action and let leadership decide on cost. One named person, not a committee, owns each action. -->

The action hierarchy in RCA2 (from the US Department of Veterans Affairs
National Center for Patient Safety) ranks actions by how much they rely
on people remembering to do the right thing. The categories below are
the hierarchy's category names; the descriptions are summaries in
original words.

| Strength | Categories | Why |
|---|---|---|
| Stronger | Architectural or physical plant changes; new devices with usability testing; engineering controls (forcing functions); simplifying the process; standardising equipment or process; tangible involvement by leadership | Change the system so the safe action is the easy or only one |
| Intermediate | Redundancy; more staff or less workload; software changes; fewer distractions; simulation-based education with refreshers and observation; checklists and cognitive aids; removing look-alikes and sound-alikes; standardised communication tools; clearer documentation | Support people at the point of work |
| Weaker | Double checks; warnings; new procedure, memorandum or policy; training | Rely on memory and vigilance |

| ID | Action *(Example)* | Addresses | Strength and category | Owner | Due |
|---|---|---|---|---|---|
| ACT-01 | Buy 8 further low beds so every Ward 4 bay has one ready; add low beds to the standard bed specification for medical wards | CS-01 | Stronger: standardise equipment | [@director-of-nursing] | [Day 120] |
| ACT-02 | Replace wall-powered sensor mats with battery mats that alarm on disconnection, selected after a usability test on the ward | CS-02 | Stronger: new device with usability testing | [@clinical-engineering-lead] | [Day 90] |
| ACT-03 | Route all night staffing gaps to the site manager, who has authority to move staff; show the live fill rate on the site dashboard | CS-03 | Intermediate: increase staffing, software change | [@deputy-director-of-nursing] | [Day 60] |
| ACT-04 | Add a picture card on night help to the bedside and demonstrate the call bell on admission, recorded on the admission checklist | CS-04 | Intermediate: checklist and cognitive aid | [@ward-manager] | [Day 45] |
| ACT-05 | Install motion-activated floor lighting from bed spaces to the bay toilets | CF-04 | Stronger: physical plant change | [@estates-manager] | [Day 150] |
| ACT-06 | Brief all Ward 4 staff on the event and the changes (temporary, until ACT-01 and ACT-02 are complete) | CS-01, CS-02 | Weaker: training | [@ward-manager] | [Day 30] |

Actions not recommended and why: [list options the team considered and
rejected, with reasons].

## 10. Measures of implementation and effectiveness

<!-- Guidance: Every action needs at least one measure. Process measures confirm the action was done; outcome measures show whether it worked. State what is measured, by whom, the expected level and the date it is checked. -->

| ID | Action | Type | Measure *(Example)* | Expected level | Measured by | Check date |
|---|---|---|---|---|---|---|
| MEA-01 | ACT-01 | Process | High-risk patients in a low bed within 4 hours of admission, audited weekly on 10 patients | 90% | [@ward-manager] | [Day 150] |
| MEA-02 | ACT-02 | Process | Sensor mats on Ward 4 that alarm when disconnected, tested monthly | 100% | [@clinical-engineering-lead] | [Day 120] |
| MEA-03 | ACT-03 | Process | Night shifts below planned staffing that were escalated to the site manager | 100% | [@deputy-director-of-nursing] | [Day 90] |
| MEA-04 | ACT-04 | Process | Admission checklists with call bell demonstration recorded, 20 records a month | 95% | [@ward-manager] | [Day 90] |
| MEA-05 | ACT-01 to ACT-05 | Outcome | Falls with moderate or greater harm per 1,000 occupied bed days on Ward 4, run chart over 12 months | Sustained reduction from baseline [rate] | [@patient-safety-lead] | [Day 365] |

## 11. Feedback to patient, family and staff

<!-- Guidance: RCA2 recommends feedback on the findings to the staff involved and to the patient or family, with a chance to comment on whether the actions make sense. Record what was shared and when. Follow your organisation's disclosure and duty of candour process. -->

| Audience | What was shared | By whom | Date | Response |
|---|---|---|---|---|
| Patient and family *(Example)* | Findings, actions and timescales in a meeting and a letter | Ward consultant and patient safety lead | [Day 40] | Daughter asked for an update when ACT-02 is in place |
| Staff involved *(Example)* | Findings and actions in a debrief, with an explicit statement that the review found system causes | Review lead | [Day 38] | [Comments] |
| Ward 4 team *(Example)* | Summary at the ward meeting | Ward manager | [Day 42] | [Comments] |
| Incident reporter *(Example)* | Outcome of the review | Patient safety team | [Day 40] | Not applicable |

## 12. Leadership review and risk acceptance

<!-- Guidance: Leadership approves the actions, decides on any action not funded, and accepts the residual risk explicitly. Only top leadership can accept risk on behalf of the organisation. -->

| Item | Decision |
|---|---|
| Actions approved | [ACT-01 to ACT-06 / list] |
| Actions not approved, with reason | [None / ACT-nn: reason] |
| Residual risk accepted until actions complete | [Description, accepted by @name] |
| Funding | [Capital request reference for ACT-01, ACT-02 and ACT-05] |
| Next review of action status | [YYYY-MM-DD, at patient safety committee] |

Leadership also reviews the RCA2 process itself at least once a year
(RCA2 recommendation 2): timeliness, the share of reviews with a
stronger or intermediate action, and how many actions were implemented
and shown to work.

## 13. External reporting and regulatory context

<!-- Guidance: Many jurisdictions and accreditors set their own rules on which events must be reported, which review method is expected and how fast. The rows below are dated examples, not a complete list. Check the current official text for your setting. -->

| Jurisdiction or body | Example framework *(as understood in October 2026; verify)* | What to check |
|---|---|---|
| England (UK) | NHS England Patient Safety Incident Response Framework (PSIRF), published August 2022, which replaced the Serious Incident Framework for NHS-funded care and favours a range of system-based learning responses over a single investigation method | Your organisation's patient safety incident response plan and policy: https://www.england.nhs.uk/patient-safety/patient-safety-insight/incident-response-framework/ |
| United States | The Joint Commission Sentinel Event Policy expects accredited organisations to complete a comprehensive systematic analysis and action plan after a sentinel event; state reporting laws and the Patient Safety and Quality Improvement Act of 2005 may also apply | The current Sentinel Event Policy chapter of your accreditation manual and your state's reporting rules: https://www.jointcommission.org/ |
| European Union | No single EU-wide incident review method; national authorities and laws set reporting and review rules | Your national health authority or patient safety agency |

| Report | Required? | Body | Deadline | Submitted | Reference |
|---|---|---|---|---|---|
| [Regulator or accreditor] | [Yes / No] | [Name] | [Date] | [YYYY-MM-DD] | [Ref] |
| [Device or medicines regulator, if equipment or a medicine was involved] | [Yes / No] | [Name] | [Date] | [YYYY-MM-DD] | [Ref] |

This section is a prompt list, not legal advice. Ask your risk
management or legal team which reports apply.

## 14. Follow-up and closure

<!-- Guidance: A review is closed when the actions are implemented and the measures show whether they worked, not when the report is approved. Record the evidence for closure. -->

| Action | Status *(Example)* | Measure result | Evidence | Closed on |
|---|---|---|---|---|
| ACT-01 | [Done] | MEA-01: [n%] | [Audit report ID] | YYYY-MM-DD |
| ACT-02 | [In progress] | MEA-02: [n%] | [Test log ID] | |
| ACT-03 | [Done] | MEA-03: [n%] | [Dashboard extract] | YYYY-MM-DD |
| ACT-04 | [Done] | MEA-04: [n%] | [Audit report ID] | YYYY-MM-DD |
| ACT-05 | [Not started: funding pending] | Not yet | [Capital request] | |
| ACT-06 | [Done] | Attendance [n of n] | [Briefing record] | YYYY-MM-DD |

**Review timeliness.**

| Milestone | Target | Actual *(Example)* |
|---|---|---|
| Event to prioritisation score | Within 72 hours | 32 hours |
| Prioritisation to first team meeting | As soon as possible | 1 day |
| Event to report to convening authority | 30 to 45 days | 36 days |
| Event to leadership approval | [Local target] | 40 days |

**Learning shared beyond the ward.** [Patient safety bulletin, other
wards with similar risks, regional network, equipment supplier if a
device issue was found.]

## 15. Glossary and references

<!-- Guidance: Define terms for readers outside patient safety and list every policy and source used. -->

### 15.1 Glossary

| Term | Meaning |
|---|---|
| Action hierarchy | A ranking of corrective actions from stronger (system changes) to weaker (reliance on memory and vigilance) |
| Blameworthy event | An event your organisation defines in advance for handling outside the safety review, for example a criminal or deliberately unsafe act |
| Causal statement | A sentence linking a cause to an effect and to the event, written to the five rules of causation |
| Close call | An event or situation that could have caused harm but did not, by chance or timely intervention |
| Convening authority | The leader who commissions the review and receives its report |
| RCA2 | Root cause analysis and action: an approach that adds strong actions and measurement to classic root cause analysis |
| SAC | Safety Assessment Code: a severity by probability score used to prioritise events |

### 15.2 References

1. National Patient Safety Foundation. *RCA2: Improving Root Cause
   Analyses and Actions to Prevent Harm*. Boston: NPSF; 2015. Version 2,
   January 2016. Available from the Institute for Healthcare
   Improvement:
   https://www.ihi.org/library/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm
2. Institute for Healthcare Improvement. Action Hierarchy tool. 2019.
   Same page as reference 1.
3. US Department of Veterans Affairs, Veterans Health Administration.
   Safety Assessment Code matrix, as reproduced in RCA2 appendix 1.
4. AHRQ Patient Safety Network. Root Cause Analysis primer (updated
   2024): https://psnet.ahrq.gov/primer/root-cause-analysis
5. [Local policies: incident management, falls prevention, disclosure]

Related templates in this collection: `healthcare/quality-improvement-report`
for a project that tests the actions, `healthcare/patient-safety-incident-report`
for the initial report and learning review, `healthcare/clinical-audit` for
measuring compliance with a standard, `business/root-cause-analysis` for
non-clinical problems, `compliance/capa-nonconformity` for regulated
quality systems, and `healthcare/sbar` for escalation during the event.

## Standard and licence note

Structure aligned with *RCA2: Improving Root Cause Analyses and Actions
to Prevent Harm* (National Patient Safety Foundation, 2015, version 2
January 2016), now distributed by the Institute for Healthcare
Improvement. RCA2 is copyright of its publisher; this template follows
its recommendations, timings and tool sequence in original words and
reproduces none of its text or examples. The action hierarchy category
names and the Safety Assessment Code matrix originate from the US
Department of Veterans Affairs National Center for Patient Safety and
are given as reproduced in RCA2. Read the official RCA2 document and
your organisation's incident policy before use, and check the current
version of any regulatory framework named in section 13. The hospital,
ward and event in the examples are fictional. This is a documentation
format, not legal or medical advice; consult qualified professionals.
Template licence: MIT.