Patient Safety Tool: Sample Form for Performing a Simple Root Cause Analysis of a Sharps Injury or Near Miss Event

Included in the Centers for Disease Control and Prevention's "Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program" is a form to assist healthcare organizations determine the factors that may have contributed to a reported sharps injury or a situation where a sharps injury could have oc­curred ("near miss").


Use of this form can assist healthcare organizations identify whether one factor or a combination of factors contributed to the problem.


The CDC says the key to the root cause analysis process is asking the question "why?" as many times as it takes to get down to the "root" cause(s) of an event.

  • What happened?
  • How did it happen?
  • Why did it happen?
  • What can be done to prevent it from happening in the future?


Use of this form and the trigger questions provided will help determine whether and how one or more of the following was a contributing factor: patient action, patient assessment, training or competency, equipment, lack of or misinterpretation of information, communication, availability and use of specific policies or procedures, healthcare personnel issues and/or supervisory is­sues.


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Download this CDC-developed, two-page root cause analysis form (pdf) for adaptation and use in your facility.


Note: View our database providing 85-plus reports that link to free, downloadable and adaptable tools for use in surgery centers, hospitals and other organizations by clicking here.


Related Articles on Sharps Safety:

23 Safe Work Practices for Preventing Sharps Injuries

Sharps Safety in Ambulatory Settings: What Would You Do?

Patient Safety Tool: Sharps Safety Educational Brochure

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