INC-2026-0008·Maternity (NICU)
Root Cause Analysis: Medication protocol variance (Wrong route) in NICU
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-00125
Why 1: The prescribed protocol was not completed as chartered.
Intelligence Hypothesis:
Moderate signal(66%)|Because:
rejectedWhat this could not see: No rostering connector data available to verify staffing density
Why 2
ATT-00126
Why 2: Staff were interrupted by an urgent bedside emergency alarm during preparation.
Intelligence Hypothesis:
Moderate signal(66%)|Because:
rejectedWhat this could not see: No rostering connector data available to verify staffing density
Why 3
ATT-00127
Why 3: The physical medication prep area lacks isolation barriers or do-not-interrupt visual cues.
Intelligence Hypothesis:
Moderate signal(66%)|Because:
rejectedWhat this could not see: No rostering connector data available to verify staffing density