Sample form for performing a simple root cause analysis

Event Tracking Number: ________

D2B Time: ________

D2B Alliance: Root Cause Analysis Template 1 of 2

Sample Form for Performing a Simple Root Cause Analysis

of a Door-to-Balloon Time >90 min

Case Information

Patient’s last name, first name: ___________________________________

Admission date (mm/dd/yyyy): __ __ / __ __ / __ __ __ __

Patient’s date of birth (mm/dd/yyyy): __ __ / __ __ / __ __ __ __

Patient’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:

Contributing Factors

If 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

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?



Personnel issues?



Supervisory issues?



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Sample form for performing a simple root cause analysis
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Sample form for performing a simple root cause analysis

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