Checklist

Root Cause Analysis: Evidence Collection & Timeline Template

Structured, interactive evidence-collection checklist with a built-in timeline builder, suggested interview guides, role assignments, action tracking slots, and a delivery/sustainment checklist so teams can run timely, complete RCAs and save structured submissions for follow-up.

Interactive Tool

Root Cause Analysis: Evidence Collection & Timeline Template

Use this interactive checklist to capture the key evidence, sequence events, interview notes, role assignments, and immediate actions when running an RCA. Save structured records so the team can prioritize fixes, assign owners, and track sustainment. Adapt fields to match your local terminology and record locations for attachments (EHR notes, device logs, video clips, etc.).

Unique identifier for this RCA or incident (use local incident number if available).
Record patient MRN or other identifier. Leave blank for non-patient events.
YYYY-MM-DD or local preferred format.
HH:MM (24h or 12h + AM/PM).
Where the event occurred (e.g., ED, ICU, OR, Radiology).
Person who initially reported or discovered the event.
Document immediate clinical or operational steps taken to secure safety and stabilize the situation.
Check every type of evidence you have collected or located.
List EHR note IDs, file shares, device log file names, video clip IDs, or physical locations so reviewers can find the original evidence.
Short guide: 1) Ask the person to describe what they observed in their own words. 2) Ask for actions and timing. 3) Ask what helped and what made the situation harder. 4) Ask whether any changes were made immediately and why.
Person interviewed.
Role at time of event.
When interview occurred.
Capture exact phrases where useful. Note contradictions with chart or logs.
Add additional interview slots as needed.
Build a chronological timeline using the event time, short description, and original source (chart, device log, interview). Accurate sequence is essential for identifying causal links.
Time or approximate time.
One-line description of what happened.
E.g., EHR note ID, device log filename, or interviewee name.
Person responsible for coordinating the RCA process.
List people invited to RCA meetings and their roles.
Describe the recommended corrective action.
YYYY-MM-DD
What will you measure to confirm the fix is sustained (e.g., medication mislabeling rate, alarm response time)?
Scheduled date to review whether actions are effective.
Who will monitor KPIs and report back.
Capture preliminary causal statements, contributing factors, and recommended corrective actions.
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