Discussion Post 3: Root Cause Analysis

I am doing clinical at the Cleveland ED in Cleveland County NC

Describe an experience with Root Cause Analysis that you had in practice or your clinical practicum using a fishbone diagram or 5 Whys method. What was the adverse event? What was your role? As a nurse leader, how would you prevent the adverse event (or near miss) from happening again?

Provide at least two references from the required reading and any additional references needed.