www.npsa.nhs.

uk/nrls

Root Cause Analysis Investigation Tools Tabular Timeline

Date/Version: Incident: Incident Ref: Lead:

Date + Time of Event: Policy / Acceptable practice: (What should have happened) *Event: (What actually happened) Additional information:
(delete on completion of timeline)

Missing Information / Data Gaps: (delete on completion

of timeline)

Notable Practice: Care Delivery Problems + Service Delivery Problems: Contributory Factors: Root Causes:
* Consider adding notes on the provenance of information gathered, particlarly if the timeline is being prepared for others to analyse

National Patient Safety Agency

Sept. 08

www.npsa.nhs.uk/nrls

National Patient Safety Agency

Sept. 08

www.npsa.nhs.uk/nrls

National Patient Safety Agency

Sept. 08

www.npsa.nhs.uk/nrls

National Patient Safety Agency

Sept. 08

www.npsa.nhs.uk/nrls

National Patient Safety Agency

Sept. 08

www.npsa.nhs.uk/nrls

Root Cause Analysis Investigation Tools Lessons Learned Log

Process Stage 1 2 3 4 5 6 7 8 9 10 Guidance Use this tool to a keep a record of what went well and what went badly, in order to share learning with others on: The incident The investigation process The Implementation of recommendations and/or action plans

Description of Experience / Observation

Conclusion / Lesson Learned

Recommendation for Action

Mechanism for Sharing Lessons learned

National Patient Safety Agency

Sept. 08

www.npsa.nhs.uk/nrls

Root Cause Analysis Investigation Tools Contributory Factors identification grid

Problem (CDP / SDP)
1

Contributory Factors / Root causes

Patient Task Individual Staff Team and Social Education and training Equipment / Communication Resources Working Condition Organisational and strategic

Guidance: Use this tool to list the Contributory Factors associated with each Care or Service Delivery Problem. This grid may be used in preference to Fishbone or Spider Diagrams

National Patient Safety Agency

Sept. 08

www.npsa.nhs.uk/nrls

Root Cause Analysis Investigation Tools

Solutions *Options Appraisal (proactive) or *Impact Analysis (retrospective) - Template (*delete as appropriate)
Risk Issue: Assessors: Date: Review Date:
RISK ASSESSMENT Before Intervention Risk reduction / Intervention Option Strength of Intervention Potential / Costs of Intervention (Staff, Advisory, Capital, Actual impact Running costs etc) on other systems
Non Recurring Recurring Time required to Implement

RISK ASSESSMENT After Intervention

Risk Reduction Potential / Impact Analysis

Severity S = 1-5

Likelihood L = 1-5

Risk Rating SxL=1-25

Describe measure Strong / Medium/Weak taken to eliminate (Eliminate, reduce significantly, reduce or reduce risk
minimally, do nothing)

Severity S = 1-5

Likelihood L = 1-5

Risk Rating (Risk Rating Before minus Risk Rating SxL=1-25 After)

Use this tool, alongside your risk matrix,:A. Proactively, to assess the potential effectiveness of solution options and assist selection B. Retrospectively, to assess the actual impact of risk reduction strategies/solutions developed as a result of investigation recommendations Assess the risk rating prior to implementation of solutions (severity of recurrence multiplied by likelihood at that severity) 1 2 Assess the strength of interventions/solutions to be implemented 3 Assess the cost of implementation Assess or measure the estimated or actual risk following implementation of solutions (severity of recurrence X likelihood at that severity) 4 Determine the expected or actual change in risk rating following implementation of solutions 5 6 Review following implementation - to ensure the risk rating has significantly reduced as expected, or if recurrence arises

National Patient Safety Agency

Sept. 08

www.npsa.nhs.uk/nrls

Root Cause Analysis Investigation Tools Action Plan - Template

Incident No:
Root CAUSE (Number as per investigation report)

Action 1

Action 2

Action 3

EFFECT on patient/service Recommendation(s) to address root cause (or rationale, if no action or recommendation is set). Number as per investigation report Action(s) to achieve recommendations (Numbered)

Level for action (organisation, directorate, team etc) Implementation by whom:Implementation by when:Resource required (time) Resource required (money) Resource required (other) Evidence of completion Monitoring and evaluation arrangements Sign-off by:-

National Patient Safety Agency

Sept. 08

www.npsa.nhs.uk/nrls

Action 4

Action 5

National Patient Safety Agency

Sept. 08

Root Cause Analysis Investigation Tools Action Plan - Template

Incident No: Root EFFECT CAUSE on patient/ (Number service as per investigati on report) Recommendation( s) to address root cause (or rationale, if no action or recommendation is set). Number as per investigation report Action(s) Level for Implemen Implemen Resource Resource Evidence Monitorin Sign-off to action tation by tation by required required of g& by:(time) (money) completi evaluatio achieve (organisat whom:when:ion, recomme on n ndations directorat arrangem (Numbere e, team ents etc) d) Sign-off Date:-

Acti ons 1