1. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 1 The RCA Process An Overview The RCA Process An Overview

2. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 2

3. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 3

4. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 4

5. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 5

6. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 6 Decision to do an RCA

7. VA National Center for Patient Safety REV.02.26.2015 7 Decision to do an RCA

8. VA National Center for Patient Safety REV.02.26.2015 8 Decision to do an RCA

9. VA National Center for Patient Safety REV.02.26.2015 9

10. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 10

11. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 11

12. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 12

13. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 13 As Needed

14. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 14

15. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 15

16. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 16 Decision to do an RCA

17. VA National Center for Patient Safety REV.02.26.2015 17

18. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 18

19. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 19

20. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 20

21. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 21

22. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 22

23. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 23

24. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 24

25. Decision to do an RCA VA National Center for Patient Safety REV.02.26.2015 25 Thank You!