Based on the findings of the root cause analysis, causal statements can be constructed. Causal statements should be:
- Accurate, non-judgemental depiction of the event(s)
- Focus on the system level vulnerabilities
- Show a clear link between causes and effects
- Prompt the development of better actions and outcome measures
Example Causal Statement:
- The instrument set up and checking process did not include a color coding or functional check mechanism, which increased the chances of a tubing misconnection not being identified.
