Discuss staff-related human performance factors that contributed to the event

Discuss staff-related human performance factors that contributed to the event



The Joint Commission Root Cause Analysis and Action Plan tool has 24 analysis questions.  The following framework is intended to provide a template for answering the analysis questions and aid organizing the steps in a root cause analysis.  All possibilities and questions should be fully considered in seeking “root cause(s)” and opportunities for risk reduction.  Not all questions will apply in every case and there may be findings that emerge during the course of the analysis.  Be sure however to enter a response in the “Root Cause Analysis Findings” field for each question #.  For each finding continue to ask “Why?” and drill down further to uncover why parts of the process occurred or didn’t occur when they should have.  Significant findings that are not identified as root causes themselves have “roots”.


As an aid to avoid “loose ends,” the two columns on the right are provided to be checked off for later reference:

  • “Root cause” should be answered “Yes” or “No” for each finding. A root cause is typically a finding related to a process or system that has a potential for redesign to reduce risk.  If a particular finding is relevant to the event is not a root cause, be sure that it is addressed later in the analysis with a “Why?” question such as “Why did it contribute to the likelihood of the event” or “Why did it contribute to the severity of the event?”  Each finding that is identified as a root cause should be considered for an action and addressed in the action plan.
  • “Plan of action” should be answered “Yes” for any finding that can reasonably be considered for a risk reduction strategy.  Each item checked in this column should be addressed later in the action plan.






When did the event occur?