Describe the issue or sentinel event for which the RCA is being conducted

Analysis of the Root Cause

Describe the issue or sentinel event for which the RCA is being conducted. Provide a clear and concise description of the problem that instigated the RCA. Your description should include information such as:

·       What happened?

·       Who detected the problem/event?

·       Who did the problem/event affect?

·       How did it affect them?

Provide an analysis of the event and relevant findings. Look to the media simulation, case study, professional experience, or another source of context that you used for the event you described. As you are conducting your analysis and focusing on one or more root causes for your issue or sentinel event, it may be useful to ask questions such as:

·       What was supposed to occur?

o   Were there any steps that were not taken or did not happen as intended?

·       What environmental factors (controllable and uncontrollable) had an influence?

·       What equipment or resource factors had an influence?

·       What human errors or factors may have contributed?

·       Which communication factors may have contributed?


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