Root Cause Analysis and Action Template (RCA2, Patient Safety)

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.

Document control

Approvals

Revision history

Contents

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

1. Event summary and immediate actions

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.

2. Risk-based prioritisation

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.

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

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.

4. Review team and charter

Charter.

5. Information gathered

6. What happened: chronology and flow diagram

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

8. Causal statements

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.

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

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.

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

10. Measures of implementation and effectiveness

11. Feedback to patient, family and staff

12. Leadership review and risk acceptance

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

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

14. Follow-up and closure

Review timeliness.

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

15.1 Glossary

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.