INC-2026-0041·General Medicine (Medical Day Unit)
Root Cause Analysis: Patient fall event (Bathroom fall) in Medical Day Unit
approved
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-00224
Why 1: The prescribed protocol was not completed as chartered.
Why 2
ATT-00225
Why 2: Staff were interrupted by an urgent bedside emergency alarm during preparation.
Why 3
ATT-00226
Why 3: The physical medication prep area lacks isolation barriers or do-not-interrupt visual cues.
Why 4
ATT-00227
Why 4: The facility layout was grandfathered without ergonomic human factors review.
Why 5Identified Root Cause
ATT-00228
Why 5 (Root Cause): Capital refurbishment guidelines lacked mandatory patient safety engineering criteria.