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.

1. What: Briefly describe the event.

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

3. Prevention: Suggest possible solutions.