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Analysis Template
Root Cause Analysis Template
Root cause analysis template
Root cause analysis template
1
2
3
Event Tracking
Number___
______
Sharps Injury Pr
evention Wor
kbook
:
A-
9
Sampl
e Form for Perf
orming a Si
mple Root Cau
se Analysis
Page 1 of 2
Sample Form for Performing a Simple Root Cause Analysis of a Shar
ps Injury or
A
Near Miss
@
Event
Description of
Event
Under Investigati
on
Event:
Date___/_
__/___ Time ___
___ AM PM
Weekday:
____________________
Location:
_______________________________________________________________________________________
Details of how the
event occurred
:
________________________________
________________________________
Contributing Factors
If
A
YES
@
, what contributed to this factor
being an issue?
Is this a root
cause of the
event?
If YES, is an
action plan
indicated?
YES
NO
YES
NO
YES
NO
Issues related to patient
assessment?
Issues related to staff
training or staff competency?
Equipment/device?
Work environment?
Lack of or misinterpretation
of information?
Communication?
Appropriate rules/policies/
procedures or lack thereof?
Failure of a protective
barrier?
Personnel or personal issues?
Supervisory issues
Download
Root cause analysis template
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