# Analyze a patient safety event with a root cause analysis

A just-culture root cause analysis of a safety event or near miss, focused on systems and processes, with strong corrective actions and measures.

- Topic: Projects & Operations
- Framework: Few-Shot
- Level: Advanced
- Tags: Analyze, Fill-in Template
- Source: https://www.thinkwithprompt.com/prompts/analyze-a-patient-safety-event-with-a-root-cause-analysis

## Prompt

```text
Help me run a root cause analysis (RCA) of a patient safety event at our clinic.

**Event type:** [e.g. wrong patient label on a specimen, missed abnormal result follow-up, medication sample dispensing error, fall in exam room, near miss]
**What happened:** [FACTUAL SEQUENCE with times, using roles not names]
**Harm level:** [no harm / near miss / temporary harm / serious harm]
**Processes and systems involved:** [e.g. EHR inbox routing, specimen labeling, check-in, handoffs]
**Contributing conditions noted so far:** [e.g. staffing, interruptions, new workflow, unclear policy]
**Team members available for the review:** [ROLES]

Work through:
1. A timeline of events and decision points.
2. What should have happened under our process versus what did happen.
3. Contributing factors across categories: communication, policies and procedures, staffing and training, equipment and EHR design, environment, patient factors, and organizational culture. Use "5 whys" for the key gaps.
4. Root causes stated as system issues, not individual blame, following just-culture principles.
5. Corrective actions ranked by strength: stronger (forcing functions, standardization, removing hazards), intermediate (checklists, redundancy, software changes), weaker (training, reminders, new policy alone). Recommend at least one stronger or intermediate action.
6. A measurement plan to verify each action works.

Return an RCA summary, a fishbone-style factor list, and an action table: Action | Strength | Owner | Due | Measure. Do not draw clinical conclusions about care quality; those belong to our medical director. If the event caused serious harm, check reporting obligations to the state, accreditor, or patient safety organization, and patient disclosure policy, with risk management.
```

## What to fill in

- FACTUAL SEQUENCE with times, using roles not names
- no harm / near miss / temporary harm / serious harm
- e.g. EHR inbox routing, specimen labeling, check-in, handoffs
- e.g. staffing, interruptions, new workflow, unclear policy
- ROLES

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