Checklist

Field RCA: Evidence Collection & Timeline Checklist

An interactive, savable checklist teams can complete during a root-cause analysis to capture evidence, reconstruct a reliable timeline, assign owners, and track follow-up actions (designed for use within 72 hours of an event).

Interactive Tool

Field RCA: Evidence Collection & Timeline Checklist

Use this interactive checklist to capture evidence and reconstruct a minute-by-minute timeline after an adverse event. Complete within 72 hours to preserve perishable evidence. Save the form to store the submission in the event record; where possible, attach or link supporting files in your site system and note locations below.

Enter your site’s incident number or local reference (optional).
Who completed this checklist? Include name and role so we can follow up if needed.
Use local timezone. Suggested format: YYYY-MM-DD HH:MM (e.g., 2026-08-25 14:35).
Describe actions taken to secure safety, isolate equipment, provide clinical care, and preserve evidence. Include names and timestamps.
List each person interviewed with role, best contact info, and interview date/time. If multiple interviews are required, add each on a new line.
Record serial numbers, lot numbers, infusion pump IDs, medication batch, barcode scans, and where physical devices are stored for inspection.
Mark yes if you have requested EHR records, medication administration logs, orders, or other system logs.
If yes above, note who requested the export, date/time requested, what was requested (e.g., medication administration record), and where the exported file or link is stored (e.g., shared drive path).
Include lighting, noise, layout, equipment placement, temperature, surface contamination, or other environmental notes.
List policies, protocols, or standard work reviewed and include version/date. Note where documents are stored or attach location references.
Reconstruct the timeline as precisely as possible. Use lines like: 'T-00:00 [HH:MM] — Event/Action — Who'. Aim for minute-level detail where available.
For each recommended action, list owner, due date, status, and evidence of completion. Example line: 'Action: Replace pump; Owner: Biomed - J. Smith; Due: 2026-08-28; Status: Open; Evidence: Work order #123'.
Timely completion helps preserve evidence. If not, explain delay in Additional Notes.
Record any file paths, shared drive links, photos, audio recordings, or other supporting evidence locations. Note if physical items were secured and where.
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