For the following questions, identify up to five causes and associated action plans that your organization will take to prevent occurrence of similar events. Include at least one root cause and one system-level action plan. Show a clear link between the cause and the action plan. A root cause identifies underlying processes and gaps in practice related to the event. A system-level action plan focuses on processes, practices, and procedures, rather than individuals, and has the greatest likelihood of preventing future occurrences. (Note: you do not need to describe your implementation plan.)