Download Root Cause Analysis Worksheet

Root Cause Analysis
Steps in a Root Cause Analysis:
1. Identify the event (overdose) and gather additional information [Columns A & B];
2. Identify contributory factors [Column C];
3. Describe the contributory factors on a timeline (0 – 12 months pre-death) [Column C];
4. Identify root causes by asking 5 “Whys”1;
5. Design changes to eliminate root causes;
6. Implement and evaluate change.
A. Identify Substances Directly
Contributing to Overdose
1. Prescription drug use:
a. Medical mishap (Rx drugs);
b. Rx drugs in combination with other
substances (alcohol, benzodiazepines,
heroin);
c. Misuse (Rx drugs).
2. Illicit Drug Use:
a. Illicit Use of Rx opioids (diversion);
b. Heroin;
c. Fentanyl.
3. Combination Use:
a. Cocaine;
b. Benzodiazepines;
c. Alcohol;
d. CNS depressants;
e. Other substances.
B. Identify Additional Information
C. Identify Contributory Factors
1. Identify the event (overdose) and gather
information:
a. Demographic Information:
i. Age;
ii. Gender;
iii. Race;
iv. Marital status;
v. Education level;
vi. Employment status;
vii. Military/veteran status;
viii. Insurance status (MA, private insurance).
b. Location of Death (geography, type);
c. Location of residence;
d. Circumstances of death (alone, with people, etc);
e. Did decedent access any of the following one year
prior to death (# of times):
i. Mental health treatment;
ii. SUD treatment;
iii. CJ system (jail, prison, etc);
iv. ED’s.
f. SUD History;
g. Dual Diagnosis (MH/SUD).
1. Identify Contributory Factors:
a. Lack of education(prescribers, patients, payers, etc);
b. Non-adherence (Rx drugs);
c. Dose escalation;
d. Polysubstance use;
e. Polypharmacy use;
f. Pain(physical, psychosocial);
g. Desire to get high;
h. Desire to avoid withdrawal;
i. Medical comorbidities;
j. Mental health comorbidities;
k. Trauma;
l. SUD history;
m. Previous overdose (non-fatal);
n. Criminal Justice System intercepts;
o. Mandatory abstinence (incarceration, treatment
programs);
p. Treatment availability (lack or inadequate);
q. Naloxone availability (lack).
2. Describe what happened (timelines):
a. Material found at scene of death;
b. How long decedent was deceased before discovery;
c. Was naloxone rescue attempted?
The “5 Whys” is a simple and effective way to identify the root cause of a problem while also uncovering the relationship between the different root causes. The “5 Whys”
method does not require a lot of resources, and it can be done without having to use statistical analyses. Simply begin by identifying the specific problem, then continue
asking “why” until the root cause is discovered. For example, Why did the person die? Because they took heroin and Fentanyl… Why did they take heroin and Fentanyl?
Because they were addicted… Why did they continue to be addicted? Because they did not receive appropriate SUD treatment, etc… Why did they not receive appropriate
SUD treatment? Because…
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