Root Cause Analysis — Worksheet
Timeline, five whys, contributory factors, and actions ranked by strength. For every high or extreme incident, in 45 days
What it is
A structured RCA worksheet: the team, the timeline, the care-delivery problems, the five whys, contributory factors by category, root causes, and an action plan ranked by strength (system redesign strongest, training and reminders weakest).
Where to use it
Safety lead with a small team not directly involved; within 45 days; the report goes to the safety committee and, for sentinel events, to ASF. Evidence for: Governance — incident analysis; Sentinel Event Policy (RCA requirement). Evidence for: Governance — incident analysis; Sentinel Event Policy (RCA requirement). Evidence for: Governance — incident analysis; Sentinel Event Policy (RCA requirement). Evidence for: Governance — incident analysis; Sentinel Event Policy (RCA requirement). Evidence for: Governance — incident analysis; Sentinel Event Policy (RCA requirement). Evidence for: Governance — incident analysis; Sentinel Event Policy (RCA requirement). Evidence for: Governance — incident analysis; Sentinel Event Policy (RCA requirement).
Translate and adapt
English master edition. Georgian and other translations are added as they are clinically reviewed. Any facility may translate, add its logo and adapt wording to local practice — keeping the ASF block, the source attribution and the licence line on the sheet. Clinical thresholds and drug doses must be confirmed against national protocols before use.
The same code is printed on the tool itself. Scan it in any facility to reach this page.
Patient Safety Incident Report
Incident Severity and Response Matrix
Just Culture — Decision Guide for Managers
Safety Learning Bulletin — Monthly, One Page
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