INCIDENT REPORTING

1. Incident Reporting & Learning System
CASE EXAMPLE

2. IDENTIFY
INCIDENTS/
ISSUES AND
INVESTIGATION/
ANALYSIS LEVEL
SELECT
INVESTIGATION
AND ANALYSIS
TEAM
PLAN AND
CONDUCT
INVESTIGATION
DETERMINE
SEQUENCE OF
EVENTS
IDENTIFY
CONTRIBUTING
FACTORS
EVALUATE
EFFECTIVENESS
OF ACTIONS
IMPLEMENT
ACTION PLAN
REPORT AND
ACTION PLAN
DEVELOP
RISK
REDUCTION/
QUALITY
IMPROVEMENT
STRATEGIES
DETERMINE
ROOT CAUSES
The 10 Step for RCA
1 2 3 4 5
6
7
8
9
10

3. GROUP #
1. TEAM MEMBER
2. TEAM MEMBER
3. TEAM MEMBER
4. TEAM MEMBER
5. TEAM MEMBER
6. TEAM MEMBER
7. TEAM MEMBER

4. Patient :
Age :
Admission Diagnosis
CASE SUMMARY

5. INCIDENTS/ ISSUES AND INVESTIGATION
/ANALYSIS LEVEL
IDENTIFY
1

6. TITLE OF INCIDENT
___________________
CASE

7. SELECT INVESTIGATION&
ANALYSIS TEAM
TEAM
2

8. TEAM
SELECTION
1. Name – Designation / Position
2. Name – Designation / Position
3. Name – Designation / Position
4. Name – Designation / Position
5. Name – Designation / Position
6. Name – Designation / Position

9. PLAN & CONDUCT
INVESTIGATION
PLAN
3

10. GATHERING
INFORMATION
1. Documents / Pictures / Interview Required
2. Documents / Pictures / Interview Required
3. Documents / Pictures / Interview Required
4. Documents / Pictures / Interview Required

11. DETERMINE SEQUENCE OF EVENTS
SEQUENCE
4

12. TABULATION
Date Time Location Event Description
Key Person
involved
Comment

13. TABULATION
Date Time Location Event Description
Key Person
involved
Comment

14. IDENTIFY CONTRIBUTING FACTORS
(WHAT, WHEN, WHERE, HOW, WHY)
FACTORS
5

15. FISH BONE DIAGRAM
INCIDENT/
ISSUE
BEING
EXPLORED
TASK &
TECHNOLOGY
FX
TEAM FX
MANAGEMENT AND
ORGANISATIONAL
FACTORS
PATIENT FX
INDIVIDUAL STAFF FX
WORK/CARE ENVIROMENT FX
EXTERNAL FX

22. EXTERNAL FACTORS :
1.
2.
3.
4.
5.
6.
7.

23. TITLE
TASK & TECHNOLOGY
FACTOR
a
a
a
PATIENT FACTOR
a
TEAM FACTOR
a
a
MX AND ORGANISATIONAL
FACTOR
a
a
INDIVIDUAL/STAFF FX
a
a
a
WORK CARE/ ENVIROMENT FX
a
EXTERNAL FX
a
NIL
a

24. Select Most Important Contributing Factor in
the Fish Bone
1
2
3

25. DETERMINE THE
ROOT CAUSE
6

26. 5 RULES OF
CAUSATION

27. 5 RULES OF CAUSATION

29. CAUSE (SEBAB)
This is Root Cause
EFFECT (KESAN)
EVENT (KEJADIAN /
INSIDEN)
MENYEBABKAN MENGAKIBATKAN
5 RULES OF CAUSATION (WORKSHEET)

30. CAUSE (SEBAB)
This is Root Cause
EFFECT (KESAN)
EVENT (KEJADIAN /
INSIDEN)
MENYEBABKAN MENGAKIBATKAN
5 RULES OF CAUSATION (WORKSHEET)

31. ROOT CAUSE
LIST OF ROOT CAUSE(S)
1.
2.
3.

32. FACTOR 1 :
CAUSE EFFECT EVENT
Use 5 Rules of Causation here
- - -

33. FACTOR 1 :
CAUSE EFFECT EVENT
Use 5 Rules of Causation here
- - -

34. FACTOR 1 :
CAUSE EFFECT EVENT
Use 5 Rules of Causation here
- - -

35. ROOT CAUSE
LIST OF ROOT CAUSE(S)
1.
2.
3.

36. DEVELOP RISK REDUCTION /
QUALITY IMPROVEMENT STRATEGIES
STRATEGIES
7

37. HIERARCHY OF RISK CONTROL

38. DRNORAISHAH@MOH.GOV.MY 38

39. DRNORAISHAH@MOH.GOV.MY 39

40. DRNORAISHAH@MOH.GOV.MY 40

41. REPORT & ACTION PLAN
REPORT
8

42. Action Planning
No.
CONTRIBUTING
FACTORS / ROOT
CAUSE
ACTION PLAN ACTION HIERIARCHY
PERSON
RESPONSIBLE
(NAME &
DESIGNATION)
EVIDENCE OF
COMPLETION /
PROGRESS
EXPECTED
COMPLETION
DATE

43. Action Planning
No.
CONTRIBUTING
FACTORS / ROOT
CAUSE
ACTION PLAN ACTION HIERIARCHY
PERSON
RESPONSIBLE
(NAME &
DESIGNATION)
EVIDENCE OF
COMPLETION /
PROGRESS
EXPECTED
COMPLETION
DATE

44. Action Planning
No.
CONTRIBUTING
FACTORS / ROOT
CAUSE
ACTION PLAN ACTION HIERIARCHY
PERSON
RESPONSIBLE
(NAME &
DESIGNATION)
EVIDENCE OF
COMPLETION /
PROGRESS
EXPECTED
COMPLETION
DATE

45. ACTION PLAN
(COVERED IN STEP 8)
IMPLEMENT
9

46. EFFECTIVENESS OF
ACTION PLAN
EVALUATE
10

47. LESSONS LEARNT
1.
2.
3.
4.
5.
6.
7.