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