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Root Cause Analysis Investigation: Action Plan - Template (Vertical)

This document provides a template for a root cause analysis action plan. The template includes columns to document the following information for each planned action: action number, root cause, effect on patient, recommendation, action to address root cause, level of action (organizational, direct, team), implementation deadline, additional required resources, evidence of progress and completion, and monitoring and evaluation arrangements. The template is intended to help document a thorough action plan following a root cause analysis investigation.

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106 views

Root Cause Analysis Investigation: Action Plan - Template (Vertical)

This document provides a template for a root cause analysis action plan. The template includes columns to document the following information for each planned action: action number, root cause, effect on patient, recommendation, action to address root cause, level of action (organizational, direct, team), implementation deadline, additional required resources, evidence of progress and completion, and monitoring and evaluation arrangements. The template is intended to help document a thorough action plan following a root cause analysis investigation.

Uploaded by

Nabi Box
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Root Cause Analysis Investigation

Action Plan - template (vertical)


See also ‘Types of Preventative Actions Planned’- tool at www.npsa.nhs.uk/rca

Action 1 Action 2 Action 3 Action 4 Action 5


Root CAUSE
EFFECT on Patient

Recommendation

Action to Address Root


Cause
Level for Action
(Org, Direct, Team)
Implementation by:

Target Date for


Implementation
Additional Resources
Required
(Time, money, other)
Evidence of Progress
and Completion
Monitoring & Evaluation
Arrangements
Sign off - action
completed date:
Sign off by:

National Patient Safety Agency - 2009


Root Cause Analysis Investigation
Action Plan – template (horizontal)
See also ‘Types of Preventative Actions Planned’ – tool at www.npsa.nhs.uk/rca

Act- Root EFFECT Recomm- Action to Level for Implemen Target Date Additional Evidence Monitoring Sign Sign
ions
CAUSE on endation Address Action -tation for Resources of & off – off
Patient Root (Org, by: Implemen- Required Progress Evaluation Action by:
Cause Direct, tation (Time, and Arrangeme compl-
Team) money etc) Complet- nts eted
ion date
1

10

National Patient Safety Agency - 2009

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