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									   Root Cause Analysis Report
           Template

Document Version number: 1.0

Date Written: 31/10/06

Author: Andrew Parkin

Job Title: Risk Management Officer

Email Address: andrew.parkin@swlondon.nhs.uk

Contact Number: 020 8812 4144

Date Approved by PCT Board: N/A

Reviewed: N/A

Next Review Date: 31/10/08

This policy can only be considered valid when viewed via the
Wandsworth PCT website. If this document is printed into hard copy or
saved to another location, you must check that the version number on
your copy matches that of the one online.

This Policy is valid on: 11 February 2010




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               Root Cause Analysis Report Template


HAVE YOU INFORMED THE PATIENT THAT A RCA IS TAKING PLACE
AND THAT THEY WILL BE INFORMED OF THE RESULT AS PER THE
PCT’S BEING OPEN POLICY ON THE PCT’S WEBSITE?

THIS REPORT SHOULD BE USED FOR LEARNING PURPOSES ONLY. IT
IS NOT TO BE USED TO APPORTION BLAME.

DO NOT USE ANY IDENTIFYING INFORMATION, USE DR X NURSE Y
E.T.C


1. Incident Description

Use this section to describe the incident and it’s consequences, using only the
facts.


2. Type of Investigation Undertaken

Use this section to describe the methods used during the investigation – team
interviews, timelines, fishbone diagrams, 5 Whys, barrier analysis etc.


3. Findings

Use this section to describe the care delivery or service delivery problems and
what the contributing factors were found to be.


4. Positive Features and Good Practice

Use this section to highlight any positive features, good practice or actions
that reduced the severity of the incident.


5. Recommendations and Action Plan

Use this section to list the recommendations and the action plan to implement
them.

Recommendation            Action                 By Whom          Due Date




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The action plan may not be available when the RCA report is written. In this
case, the action plan may be sent at a later date so as not to delay the
publication of the RCA report’s findings.


WRITTEN BY
POSITION
DATE



6. Appendices

Use this section to record:

Lists of documents used
Copies of any relevant documents or relevant sections
Electronic versions of annotated fishbone diagrams, time lines, barrier
analysis tables etc.


THE REPORT SHOULD BE MADE AVAILABLE TO THE PATIENT AS
PART OF THE BEING OPEN PROCESS.




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