Root Cause Analysis

Description: Identify an adverse event or near miss that occurred during the rotation. This is not an indictment on anyone so please do not use names and make every effort to protect privacy. Perform a root cause analysis of the problem by clearly stating 1. what happened, 2. why it happened, and 3. what can be done to prevent it from happening again. When addressing why it happened, you will usually need to identify others involved in the chain of events and ask them “why?”. Keep asking “why?” at every stage of your probing until you get to the point you think you have identified the root cause. Only then will you be able to propose a solution to prevent it happening again.

Optional Submission Instructions: The following is a suggested format for writing up the incident and it should take no more than a page. Alternatively, 3-4 students in your group would like to discuss, rather than write-up the event, I am happy to arrange a time for a small group discussion that would still follow the same general format below.

1. What: Briefly describe the event.

2. Why: Identify the root potential cause(s) of the adverse event.

3. Prevention: Suggest possible solutions.