1. Root Cause Analysis Quality and Patient Safety Council
August 12, 2009
Privileged and Confidential Under the Ohio Revised Code. The documents contained within are confidential professional/ peer review and quality assessment documents of the UTMC. It is protected from disclosure pursuant to the provisions of ORC , ORC , and ORC Unauthorized disclosure or duplication is absolutely prohibited.

2. Sentinel Event/Adverse Event/RCA

3. Case Summary

4. Root Cause (s)

5. Contributing Factors

6. Contributing Factors

7. Other Investigatory Findings

8. Risk Reduction Strategies

9. Further Discussion–Final Approval