INC-2026-0016·Emergency (Resus)
Root Cause Analysis: Flow rate programming variance on Becton Dickinson Alaris Guardrails (Unit #S-412) in Resus
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-00149
Why 1: The prescribed protocol was not completed as chartered.
Intelligence Hypothesis:
Strong signal(82%)|Because:
editedWhy 2
ATT-00150
Why 2: Staff were interrupted by an urgent bedside emergency alarm during preparation.
Intelligence Hypothesis:
Strong signal(82%)|Because:
editedWhy 3
ATT-00151
Why 3: The physical medication prep area lacks isolation barriers or do-not-interrupt visual cues.
Intelligence Hypothesis:
Strong signal(82%)|Because:
edited