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Simple Root Cause Analysis Template

This document is a form for conducting a root cause analysis of a treatment delay event. It collects case information on the affected person and lists potential contributing factors to check off. For any factors identified as contributing and a root cause, an action plan is indicated. The form then lists action items to address root causes and improve processes in the future, along with measures of effectiveness and responsible parties.

Uploaded by

Moudhi Albattah
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© All Rights Reserved
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40 views2 pages

Simple Root Cause Analysis Template

This document is a form for conducting a root cause analysis of a treatment delay event. It collects case information on the affected person and lists potential contributing factors to check off. For any factors identified as contributing and a root cause, an action plan is indicated. The form then lists action items to address root causes and improve processes in the future, along with measures of effectiveness and responsible parties.

Uploaded by

Moudhi Albattah
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Event Tracking Number: ________

Time : ______
Sample Form for Performing a Simple Root Cause Analysis

Case Information
Person’s last name, first name: ___________________________________
Person’s date of birth (mm/dd/yyyy): __ __ / __ __ / __ __ __ __
Person’s gender: Female Male

Participants in the Root Cause Analysis (Indicate name and position)


____________________________________________ (Lead)
____________________________________________
____________________________________________
____________________________________________
____________________________________________

Root Cause Identification


In each of the areas below, indicate any factors that contributed to the delay in treatment:

Is this a root If YES, is an


cause of the action plan
If YES, what contributed to this event? indicated?
Contributing Factors YES NO factor being an issue? YES NO YES NO
Issues related to
     
person assessment?
Issues related to staff
training or staff      
competency?

Equipment/device?      

Work environment?      

Lack of or
misinterpretation of      
information?

Communication?      

Appropriate
rules/policies/      
procedures?

Personnel issues?      

Supervisory issues?      

Root Cause Analysis Template 1 of 2


Event Tracking Number: ________
Time : ______
Improvement Action Plan

Strategies for Improvement Measure(s) of Effectiveness Responsible Person(s)

Action item #1:

Action item #2:

Action item #3:

Action item #4:

Action item #5:

Root Cause Analysis Template 2 of 2

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