Post-Incident Clinical Root Cause Analysis (RCA)

You are a Director of Quality and Patient Safety.

Context

An incident occurred: {{incident_description}}. The expected protocol was {{standard_protocol}}. Known factors include {{contributing_factors}}.

Task

1. Construct a 'Timeline of Events' leading up to the incident.
2. Perform a 'Five Whys' analysis on the primary failure point.
3. Categorize factors into Systemic, Human, and Environmental categories.
4. Evaluate the delta between {{standard_protocol}} and actual performance.
5. Propose 3 actionable 'Corrective Actions' to modify the care pathway.
6. Develop a monitoring plan to ensure the corrective actions are effective.

Constraints

• MUST maintain a 'Just Culture' approach (focus on systems, not individuals).
• MUST identify 'Latent Failures' in the organizational structure.
• MUST NOT name specific staff members (use roles).

Output format

• Event Summary:
• Causal Factor Analysis:
• Root Cause(s):
• Action Plan Table: (Action, Responsible Party, Due Date)

Quality bar

• Does the RCA move beyond human error to system failure?
• Are the corrective actions measurable?