1. What happened: What departments were involved? What are the details of the event? What was the missing or weak step in the process? What caused the missing or weak step in the process? What is currently done to prevent failure at this step?
  • Why did it happen: What was the human error? Was staff performance in the process addressed: Was staff properly qualified? Was staffing adequate? Can orientation and in-service training be improved?
  • Why did it happen: Was all secondary information available – when recorded? Accurate? Complete? Is communication among participant adequate? Are there barriers to communication? Is prevention of adverse outcomes considered a high priority?
  • Why did it happen: How did the equipment fail? What broke? What is currently being done to prevent an equipment failure? What is currently being done to protect against a bad outcome if an equipment failure does occur?
  • Why did it happen: What environmental factors directly affected the outcome? Was the physical environment appropriate for the process to be carried out? Are systems in pace to identify environmental risks? Are responses to environmental risks planned and tested?
  • Why did it happen: Were there any uncontrollable external factors? Are they truly beyond the organization’s control? How can we protect against them?
  • Why did it happen: Were there any other factors that directly influenced the outcome? What caused the breakdown at this step in the process? How can we protect against them?

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