INC-2026-0017·Pharmacy (Aseptic Unit)
Root Cause Analysis: Patient fall event (Call-bell delay) in Aseptic Unit
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-00152
Why 1: The prescribed protocol was not completed as chartered.
Why 2
ATT-00153
Why 2: Staff were interrupted by an urgent bedside emergency alarm during preparation.
Why 3
ATT-00154
Why 3: The physical medication prep area lacks isolation barriers or do-not-interrupt visual cues.