TTline.lessonsLL.cf Grid.opt App.act Plan (1)

7/28/2019 TTline.lessonsLL.cf Grid.opt App.act Plan (1)

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www.npsa.nhs.uk/nrls

Root Cause Analysis Investigation Tools

Tabular TimelineDate/Version:

Incident:

Incident Ref:

Lead:

* Consider adding notes on the provenance of information gathered, particlarly if the timeline is being prepared for others to analyse

Date + Time of Event:

*Event: (What actuallyhappened)

Contributory Factors:

Root Causes:

Additional information:(delete on completion of timeline)

Missing Information /

Data Gaps: (delete on completionof timeline)

Notable Practice:

Care Delivery Problems +

Service Delivery Problems:

Policy / Acceptable

practice: (What should have

happened)

National Patient Safety Agency Sept. 08


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Lessons Learned Log

Process

Stage

Description of Experience /

Observation

Conclusion / Lesson

Learned

Recommendation for

Action

Mechanism for Sharing

Lessons learned

1

2

3

4

5

6

7

8

910

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



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Contributory Factors identification grid

Problem

(CDP / SDP) Patient Task Individual Staff Team and Social Education and

training

Equipment /

Resources

Communication 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

Contributory Factors / Root causes

1

2

4

3



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Root Cause Analysis Investigation ToolsSolutions *Options Appraisal (proactive) or*Impact Analysis (retrospective) - Template (*delete as appropriate)

Assessors:

Review Date:

Risk reduction /

InterventionOption

Strength of

Intervention

Potential /

Actual impacton other

systems

Risk Reduction

Potential / ImpactAnalysis

Severity

S = 1-5

Likelihood

L = 1-5

Risk Rating

SxL=1-25

Describe measure

taken to eliminate

or reduce risk

Strong / Medium/Weak

(Eliminate, reduce

significantly, reduce

minimally, do nothing)

Non

Recurring

Recurring

Severity

S = 1-5

Likelihood

L = 1-5

Risk Rating

SxL=1-25

(Risk Rating Before

minus Risk Rating

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

1 Assess the risk rating prior to implementation of solutions (severity of recurrence multiplied by likelihood at that severity)

2 Assess the strength of interventions/solutions to be implemented

3 Assess the cost of implementation4 Assess or measure the estimated or actualrisk following implementation of solutions (severity of recurrence X likelihood at that severity)

5 Determine the expected or actual change in risk rating following implementation of solutions

6 Review following implementation - to ensure the risk rating has significantly reduced as expected, or if recurrence arises

Time

required toImplement

Risk Issue:

RISK ASSESSMENT

After Intervention

RISK ASSESSMENT

Before Intervention

Date:

Costs of Intervention

(Staff, Advisory, Capital,Running costs etc)


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Action Plan - Template

Incident No: Action 1 Action 2 Action 3 Root CAUSE (Number as per

investigation report)

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)


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Action 4 Action 5


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Action Plan - Template

Incident No:

Acti

ons

Root

CAUSE

(Number

as per

investigati

on report)

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

recomme

ndations

(Numbere

d)

Level for

action

(organisat

ion,

directorat

e, team

etc)

Implemen

tation by

whom:-

Implemen

tation by

when:-

Resource

required

(time)

Resource

required

(money)

Evidence

of

completi

on

Monitorin

g &

evaluatio

n

arrangem

ents

Sign-off

by:-

Sign-off

Date:-

1

2

3

4

5

TTline.lessonsLL.cf Grid.opt App.act Plan (1)

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