Sample Form For Performing A Simple Root Cause Analysis Of An Injury Or A Near Miss Event

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Event Tracking Number_________
Sample Form for Performing a Simple Root Cause Analysis of a Sharps Injury or
ANear Miss@ Event
Description of Event Under Investigation
Event: Date___/___/___ Time ______ AM PM
Weekday: ____________________
Location: _______________________________________________________________________________________
Details of how the event occurred: ________________________________________________________________
Is this a root
If YES, is an
cause of the
action plan
event?
indicated?
If AYES@, what contributed to this factor
Contributing Factors
being an issue?
YES
NO
YES
NO
YES
NO
Issues related to patient
assessment?
Issues related to staff
training or staff competency?
Equipment/device?
Work environment?
Lack of or misinterpretation
of information?
Communication?
Appropriate rules/policies/
procedures or lack thereof?
Failure of a protective
barrier?
Personnel or personal issues?
Supervisory issues
A-9 Sample Form for Performing a Simple Root Cause Analysis
Page 1 of 2
Sharps Injury Prevention Workbook:

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