| name | rca-investigation |
| description | Healthcare Root Cause Analysis (RCA) and Serious Adverse Event (SAE) investigation skill for AU/NZ clinical governance. Use when: conducting an RCA or SAE review; classifying incident severity (SAC 1-4) and selecting investigation methods; executing structured analysis using Fishbone, 5 Whys, Yorkshire Framework, SEIPS, Swiss Cheese, Bow-Tie, Barrier Analysis, FMEA, Timeline, HFACS, London Protocol, AcciMap, STAMP/STPA, or RCA²; generating investigation reports, DOCX governance documents, PPTX presentations, or Mermaid diagrams; creating CAPA action plans; assessing Just Culture; or linking RCA findings to quality improvement. Integrates with health-incident-reporting, health-clinical-risk-assessment, health-quality-improvement, and health-enterprise-risk-assessment skills.
|
RCA & SAE Investigation
Operating Modes
| Mode | When | Agent |
|---|
| Triage | New incident — classify, prioritize, select methods | agents/rca-triage.md |
| Investigate | Active investigation — execute analysis method(s) | agents/rca-investigate.md |
| Report | Analysis complete — generate reports, diagrams, documents | agents/rca-report.md |
| Track | Report accepted — CAPA, QI linkage, effectiveness review | agents/rca-track.md |
Quick Method Selection
Read references/method-selection-matrix.md for the full decision framework.
By SAC level:
- SAC 1 (catastrophic): Timeline + Yorkshire + Bow-Tie + SEIPS
- SAC 2 (major): Timeline + Yorkshire + Fishbone or London Protocol
- SAC 3 (moderate): 5 Whys + Contributing Factors
- SAC 4 (minor/near miss): 5 Whys
- Proactive: FMEA + Bow-Tie
Methods Reference Index
| Method | File | Best For |
|---|
| RCA² | references/methods/rca-squared.md | Enhanced RCA with action focus |
| 5 Whys | references/methods/five-whys.md | Simple, rapid cause drilling |
| Fishbone/Ishikawa | references/methods/fishbone.md | Structured cause-effect categorization |
| Yorkshire Framework | references/methods/yorkshire-framework.md | Comprehensive contributing factors (SOTA) |
| SEIPS 3.0 | references/methods/seips.md | Work system model |
| Swiss Cheese | references/methods/swiss-cheese.md | Defence-in-depth failure analysis |
| Bow-Tie | references/methods/bow-tie.md | Threat-barrier-consequence mapping |
| Barrier Analysis | references/methods/barrier-analysis.md | Failed/missing barrier identification |
| FMEA | references/methods/fmea.md | Proactive failure mode analysis |
| Timeline Analysis | references/methods/timeline-analysis.md | Event sequencing, gap identification |
| HFACS | references/methods/hfacs.md | Human factors classification |
| London Protocol | references/methods/london-protocol.md | Systematic clinical investigation |
| AcciMap | references/methods/accimap.md | Multi-level systemic accident mapping |
| STAMP/STPA | references/methods/stamp-stpa.md | Systems-theoretic accident model |
Template Index
Mermaid Diagrams (assets/templates/mermaid/)
fishbone-ishikawa.mmd — Cause-effect mindmapswiss-cheese-model.mmd — Defence layersbow-tie-analysis.mmd — Threat-barrier-consequencetimeline-chronology.mmd — Event sequencefive-whys-chain.mmd — Causal chainseips-work-system.mmd — Work system modelyorkshire-factors.mmd — Contributing factor mapaccimap-levels.mmd — Multi-level systemic maphfacs-layers.mmd — Human factors pyramidstamp-control-structure.mmd — Control structureinvestigation-workflow.mmd — Investigation processfmea-priority-quadrant.mmd — Severity vs likelihood
Working Document Templates (assets/templates/markdown/)
01 Investigation Terms of Reference | 02 Chronology | 03 Contributing Factors |
04 Fishbone Diagram | 05 FMEA Worksheet | 06 Barrier Analysis |
07 Bow-Tie Analysis | 08 RCA Investigation Report | 09 SAE Review Report |
10 Executive Summary | 11 CAPA Action Plan | 12 Open Disclosure Plan |
13 Investigation Closure | 14 Just Culture Assessment
DOCX Templates (assets/templates/docx/)
RCA Investigation Report | SAE Review Report | Executive Briefing |
Terms of Reference | CAPA Action Plan | Open Disclosure Record | Investigation Closure
PPTX Templates (assets/templates/pptx/)
Governance Committee Brief | Learning Presentation | Executive Summary Deck
Key References
references/method-selection-matrix.md — Which method(s) for which eventreferences/method-combination-guide.md — How to combine methodsreferences/just-culture-guide.md — Human error vs at-risk vs recklessreferences/safety-ii-principles.md — Resilience engineering lensreferences/investigation-quality-checklist.md — ACSQHC standards self-assessment
Privacy
De-identify all patient data: use [Patient A], [Case ID], [Ward X].
Investigation reports may be legally privileged — mark CONFIDENTIAL: QUALITY IMPROVEMENT.
