Framework for Conducting a Root Cause Analysis and Action Plan

What was the intended process flow? Were there any steps in the process that did not occur as intended? What human factors were relevant to the outcome? How did the equipment performance affect the outcome? What controllable environmental factors directly affected this outcome? What uncontrollable external factors influenced this outcome? Were there any other factors that directly influenced this outcome? What are the other areas in the organization where this could happen? Was the staff properly qualified and currently competent for their responsibilities at the time of the event? How did actual staffing compare with ideal levels? What is the plan for dealing with staffing contingencies? Were such contingencies a factor in this event? Did staff performance during the event meet expectations? To what degree was all the necessary information available when needed? Accurate? Complete? Unambiguous? To what degree was the communication among participants adequate for this situation? Was this the appropriate physical environment for the processes being carried out for this situation? What systems are in place to identify environmental risks? What emergency and failure- mode responses have been planned and tested? How does the organization’s culture support risk reduction? What are the barriers to communication of potential risk factors? How is the prevention of adverse outcomes communicated as a high priority? How can orientation and in-service training be revised to reduce the risk of such events in the future? Was available technology used as intended? How might technology be introduced or redesigned to reduce risk in the future?                                                        

Sample Solution