Patient Safety Root Cause Analysis (RCA) Checklist

Form Template

The Patient Safety Root Cause Analysis (RCA) Checklist should be completed by a patient safety specialist after an incident has occurred.

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Aside from documenting the details of the event, including the patients name and a description of the event, the root cause analysis will investigate the situation to ultimately improve patient safety, ensuring that everyone who needs to be notified has been and that all paperwork is up to date. A meeting will be scheduled to review the files and documentation to see what factors lead to the incident. Staff members involved in the incident should be identified and join in the discussion to develop an action plan that will include corrective actions and minimize risk to the patients and staff members. Medical errors, such as wrong-site surgery can happen in a hospital, but if staff members, doctors, and all other stakeholders focus on solutions, they can work to prevent these types of incidents and focus on health and safety of patients.

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