Abstract: Objective The retrospective analysis was conducted on three cases of adverse events involving swallowing and aspiration in our hospital by applying the root cause analysis method. Methods The root causes of the events were identified in terms of systematic processes by creating a cause-and-effect diagram. Results The root causes of these incidents were identified in the system process: the lack of standardized preventive measures, insufficient patient evaluation, inadequate preoperative precautionary measures, and treatment positions that could easily result in swallowing and aspiration. Conclusion To address these three root causes, specific improvement measures were implemented: conducting adequate preoperative patient evaluations, enhancing preoperative precautionary measures, adjusting patient treatment positions, strengthening preventive measures during procedures, and enhancing supervision of such incidents.

Key words: Root cause analysis, Swallowing and aspiration, Adverse events