A Root Cause Analysis (RCA) is an identification of strategies to prevent the recurrence of an event through a multidisciplinary system analysis of a patient safety incident (DoD Patient Safety Program, 2016). Every health care providers’ worst nightmare is being involved in an event like the one on the video. Explaining with the team the importance of finding the flaws in the system than pointing fingers and encouraging the team to “search for the best risk-reduction strategies” in order to develop an action plan that will prevent this kind of event from happening is the goal of RCA (Keating & Tocco, 2013, p. 59). Being mindful to stay alert and try to deal with the risk as it happens, as well as preventing it from happening again
