INC-2026-0002·Facilities (Sterile Supply (CSSD))
Root Cause Analysis: Equipment discrepancy (Tubing misconnection) in Sterile Supply (CSSD)
in progress
Iterative interrogative technique to explore cause-and-effect relationships underlying the event.
5 Whys Causal Pathway Analysis
Progressive causal interrogation drilling from clinical symptom to systemic safeguard failure.
Why 1
ATT-00107
Why 1: The prescribed protocol was not completed as chartered.
Why 2
ATT-00108
Why 2: Staff were interrupted by an urgent bedside emergency alarm during preparation.
Why 3
ATT-00109
Why 3: The physical medication prep area lacks isolation barriers or do-not-interrupt visual cues.