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ISMP Community Pharmacy Template for
Root Cause Analysis and Action Plan
This template is provided as an aid to organizing/displaying the steps in a RCA. Not all possibilities and questions will apply in every case, and there may
be others that will emerge in the course of the analysis. However, all possibilities and questions should be fully considered in your quest to identify root
causes, contributing factors and associated risk reduction strategies.

Step 1 - RCA Title:
Date/Time Range of Event:
Problem Statement:

Team Members
Team leader:
Individual with knowledge about the event:
Frontline worker familiar with process (but not directly involved with the event):

RCA expert (optional: someone who works in medication safety such as a risk manager, an outside consultant or a respected
pharmacist from another pharmacy who can look at the event objectively to properly guide this process):

ISMP — ROOT CAUSE ANALYSIS WORKBOOK FOR COMMUNITY/AMBULATORY PHARMACY

Community Pharmacy Templ