Do these causes apply to every hospital?

No. They are examples of common situations. A real analysis rests on the investigation of the event and follows your institution's policies.

How do we keep the analysis from turning into blame?

Write system and process problems only, with no names. The purpose of root cause analysis is to improve the process, not to find who made a mistake.

Set an action for each key cause with an owner and a date, then check the rate of similar events to see whether it worked.

Patient fall root cause fishbone diagram template

Previewed in the “Paper” theme; you can switch themes in the editor

When to use it

Use it for a root cause analysis after a safety event, the cause analysis step of a quality improvement project, or a report to a quality committee. The six bones are angles commonly used in nursing safety. The example is a fall; for a medication error, pressure injury or dislodged line, change the problem and the causes.

Make it yours

Change the second line to the event type, and leave out names, bed numbers and anything that identifies a patient.
Take causes from the event report, the scene and interviews; write facts, not blame.
Adjust categories for other events, such as adding "Medication management" for a medication error.
Indent with spaces only and keep lines on the same level aligned.

Mermaid code

nursing-incident-fishbone.mmd

ishikawa-beta
    Inpatient fall
    Staff
        Night shift understaffed
        Fall risk assessment not updated
    Patient factors
        Older adult with unsteady gait
        Got up without calling for help
    Environment
        Wet floor
        Poor lighting at night
    Policies
        Rounding intervals too long
        Fall prevention teaching done as a formality
    Equipment
        Bed rails left down
        Call button out of reach
    Communication
        High-risk patient not flagged at handover
        Family not told how to assist

Ask an AI for one with this structure

Send the prompt below to ChatGPT or Claude, then paste the whole reply into the editor; the code inside is detected automatically.

prompt.txt

Draw a fishbone diagram with Mermaid ishikawa-beta syntax that analyzes the causes of an inpatient fall. Write ishikawa-beta on the first line and the problem, indented, on the second. Below it add one line each for Staff, Patient factors, Environment, Policies, Equipment and Communication, with two specific causes indented one level deeper under each. Indent with spaces only and write plain text on each line. Output only the mermaid code block.

FAQ

Do these causes apply to every hospital?: No. They are examples of common situations. A real analysis rests on the investigation of the event and follows your institution's policies.
How do we keep the analysis from turning into blame?: Write system and process problems only, with no names. The purpose of root cause analysis is to improve the process, not to find who made a mistake.
How do we follow up?: Set an action for each key cause with an owner and a date, then check the rate of similar events to see whether it worked.

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Updated 2026-11-11