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• Think back to a critical incident in your workplace that affected patient safety, had unintended outcomes, or did not contribute to the well-being of the patient. Reflect on the incident to identify why the breakdowns in quality and safety occurred.
• Refer to Box 5-4, Guidelines for Analyzing CT (Rubenfeld & Scheffer, 2015, p. 139) in your text to examine an event/incidence, to synthesize what happened, and how to prevent it in the future.

Write a two to three-page paper (excluding title page and reference page) that includes:

• A description of a critical incident that occurred in your workplace that had unintended outcomes or did not contribute to the well-being of the patient.
• An analysis of the event using the questions from box 5-4. Use these questions to analyze the event – it is not necessary to use all of them, but the ones that pertain to your event. You can then use the information from your answers to identify and talk about the incident and what worked well and what did not.
• Your reflection of the incident, what the breakdowns were and why they occurred.
• What steps a leader/manager can take to prevent future incidents. Or describe how you would create an environment where these incidences are less likely to happen. For example, what would you do differently?