INC-2026-0014·Radiology (Ultrasound)
Root Cause Analysis: Procedural safety observation (Surgical site verification) in Ultrasound
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-00143
Why 1: The prescribed protocol was not completed as chartered.
Why 2
ATT-00144
Why 2: Staff were interrupted by an urgent bedside emergency alarm during preparation.
Why 3
ATT-00145
Why 3: The physical medication prep area lacks isolation barriers or do-not-interrupt visual cues.