1. Introduction
2. Example: Eye Splash & Needle Stick Incidents
3. Definitions
4. Confusing Causes & Effects
5. Widespread Over Confidence
6. Too Long to Wait
7. Consistency Checks
8. Bayesian Networks
9. Links Between Graphs & Probabilities
10. Conditional Independence in Serial Graph
11. Conditional Independence in Diverging Graph
12. Conditional Independence in Complex Graphs
13. Identify Conditional Independencies in the Graph
14. Prediction from Root Causes
15. Estimate Probabilities
16. Estimated Marginal Probabilities
17. Estimated Conditional Probabilities
18. Estimated Sentinel Probabilities
19. Probability of Sentinel Event
20. Probability of Sentinel Event Given Three Causes
21. Reverse Predictions
22. Prevalence of Cause among Sentinel Events
23. Signal to Re-think
24. Traditional Steps in Conducting Root Cause Analysis
25. Proposed Additional Steps
26. Take Home Lesson