The problem with this "root cause analysis" is that it assumed that the MRI, requested by a neurologist on-call, via telephone, was necessary. It was not. The root cause analysis got it wrong because it did not trace the roots to their deepest source: glossing over the patient's chief complaint and considering it and its evaluation carefully and rationally. Stroke is an uncommon cause of dizziness and the MRI was probably not indicated, especially in light of the other information provided in the case.
Here is the letter that I sent to JAMA which was not accepted/published. It is a case of the distinction between rationality and intelligence. Very intelligent people traced the "cause" or the "root" of the complication to a missed piece of information (OSA) and corollary ideas (he may have complications from sedation), but they failed to consider underlying assumptions: namely that the MRI was necessary or would yield net benefit in the first place.
Medicine is best played like chess, not like checkers. "Intelligent people have superior performance when you tell them what to do." A failure of a "root cause analysis" such as this will foment the regrowth of the weed.
Here is the letter: