r o o t c a u s e a n a l y s i s f o r m- connecticut（r o o t c u s e n l y s i f s o r m -康涅狄格）.doc

ROOT CAUSE ANALYSIS REPORT FORM AGENCY: Reference No.: Program/Facility: Region STS North South West Consumer ID: Age: Gender: M F MR Level: NR ML MO SV PR City/Town: Date of Event: Date RCA Completed: 1. THE EVENT – Describe what happened and any harm that resulted. Identify the proximate cause, if known. RCA Team Members: Team Leader: 2. BACKGROUND FACTORS SUMMARY– Answer the following questions (brief summary only- attach supporting documents). 2.1 What was the sequence of events that was expected to take place? Attach flowchart if available. Description: 2.2 Was there a deviation from the expected sequence? Yes No If YES, describe the deviation. Attach flowchart if available. 2.3 Was any deviation from the expected sequence likely to have led to or contributed to the adverse event? Yes No NK If YES, describe with causal statement. 2.4 Was the expected sequence described in policy, procedure, written guidelines, or included in staff training? Yes No NK If YES, cite source. 2.5 Does the expected sequence or process meet regulatory requirements and/or practice standards? Cite references and/or literature reviewed by the team. Yes No NK If NO, describe deviation from requirements/standards. 2.6 Did human action or inaction appear to contribute to the adverse event? Yes No NK If YES, describe the actions and how they contributed. 2.7 Did a defect, malfunction, misuse of, or absence of equipment appear to contribute to the event? Yes No NK If YES, describe what equipment and how it appeared to contribute. 2.8 Was the procedure or activity involved in the event being carried out in the usual location? Yes No NK If NO, describe where and why a different location was utilized. 2.9 Was the procedure or activity being carried out by regular staff familiar with the consumer and activity? Yes No NK If NO, describe who was carrying out the activity and why regular staff were no