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how did this situation arise?

Select 1 of the cases on the document posted with this assignment.
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…in no less than 2 pages (double spaced, 12 point Times New Roman Font)
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…answer the questions associated with the case study
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…be sure to focus on the following three things:
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How did this situation arise?
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What should be done to fix the issues?
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What is the best way to prevent situations like this systematically?
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There is an example case study for reference