rca-investigation

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 mindmap
• swiss-cheese-model.mmd — Defence layers
• bow-tie-analysis.mmd — Threat-barrier-consequence
• timeline-chronology.mmd — Event sequence
• five-whys-chain.mmd — Causal chain
• seips-work-system.mmd — Work system model
• yorkshire-factors.mmd — Contributing factor map
• accimap-levels.mmd — Multi-level systemic map
• hfacs-layers.mmd — Human factors pyramid
• stamp-control-structure.mmd — Control structure
• investigation-workflow.mmd — Investigation process
• fmea-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 event
• references/method-combination-guide.md — How to combine methods
• references/just-culture-guide.md — Human error vs at-risk vs reckless
• references/safety-ii-principles.md — Resilience engineering lens
• references/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.