New Jersey Department of Health

ROOT CAUSE ANALYSIS (RCA)

OF A Serious Preventable Adverse Event	NJDOH Internal use only
Report No.
This form must be completed for any serious preventable adverse event. All information is protected based on the provisions of the Patient Safety Act [N.J.S.A. 26:2H-12.25(f)]

SECTION A - GENERAL INFORMATION
1. FACILITY IDENTIFICATION
Facility Name:	Facility License No.:
Facility Street Address:	County:
City:	State:	Zip Code:
Name of Person Submitting:	Telephone No.:
Title or Position:	Fax No.:
Email Address:
SECTION B - EVENT INFORMATION
2. EVENT DATE:	Time:	AM	PM
Date Initial Report of Adverse Event Sent to NJDOH:	DHSS Report Number (Assigned by NJDOH):
Medical Record Number:	Patient/Resident Billing Number:
Patient/Resident Name:
Principal Diagnosis with ICD-9 Code:
Medical Diagnoses Resulting from the Adverse Event with ICD-9 Code(s):
SECTION C - ROOT CAUSE ANALYSIS
3. SELECT ROOT CAUSE (Select all that apply):

Adequacy of technical support	Labeling of medications

Availability of information	Orientation and training of staff

Behavioral assessment process	Patient identification process

Care planning process	Patient observation procedures

Communication among staff members	Physical assessment process

Communication with patient/family	Physical environment

Competency assessment/credentialing	Security systems and processes

Control of medications (Storage/access)	Staffing levels

Equipment maintenance/management	Supervision of staff
Other:

4. WHAT WERE THE CONTRIBUTING FACTORS TO EVENT (Select all that apply):

Equipment	Patient record documentation

Home Care	Procedures

Imaging and X-rays	Staff factors

Laboratory and diagnostics	Task factors

Medical Device	Team factors

Medications	Transportation

Organizational/management	Work environment

Patient characteristics	Other (Specify):
5. EVALUATE IMPACT OF EVENT FOR PATIENT/RESIDENT (Select all that apply):

Additional laboratory testing or diagnostic imaging	Loss of organ(s)

Additional patient monitoring in current location	Loss of sensory function(s)

Disability - physical or mental impairment	Major surgery

Hospital admission	Minor surgery

Increased length of stay	Other additional diagnostic testing

Loss of bodily function(s)	System or processes delay care to a patient

Loss of body part(s)	To be determined

Loss of digit(s)	Transfer to more intensive level of care

Loss of limb(s)	Visit to Emergency Department

Other (Specify):	Death
6. DESCRIBE ROOT CAUSE ANALYSIS:

(Attach the RCA.)

New Jersey Department of Health

ROOT CAUSE ANALYSIS (RCA)

OF A Serious Preventable Adverse Event

(Continued)	NJDoh Internal use only
Report No.

HCQ-2

AUG 12	Page 2 of 2 Pages.

AUG 12	Page 1 of 2 Pages.

HCQ-2, Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility, (Root Cause Analysis), (RCA)

HCQ-2, Report of Serious Preventable Adverse Event in a NJ Licensed Health Care Facility, Root Cause Analysis, (RCA), health care quality, preventable adverse event, report, hcqo-20

EWhite

2004-11-17

NJDOH