Healthcare Adverse Event RCA Worksheet
Event Information
Date of Event
Time
Location
Department/Unit
Event Type
Patient(s) Involved
Event Description
Contributing Factors
Human Factors
System/Process Factors
Equipment/Technology
Environment
Communication
Other
Root Cause Analysis
Actions Taken/Recommended
Action
Person Responsible
Due Date
Status
Lessons Learned
Prepared By
Name(s)
Date