INC-2026-0043·Surgical (Recovery)
Root Cause Analysis: Documentation variance (Verbal order handover) in Recovery
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-00230
Why 1: The prescribed protocol was not completed as chartered.
Intelligence Hypothesis:
Moderate signal(71%)|Because:
rejectedWhat this could not see: No rostering connector data available to verify staffing density
Why 2
ATT-00231
Why 2: Staff were interrupted by an urgent bedside emergency alarm during preparation.
Intelligence Hypothesis:
Moderate signal(71%)|Because:
rejectedWhat this could not see: No rostering connector data available to verify staffing density
Why 3
ATT-00232
Why 3: The physical medication prep area lacks isolation barriers or do-not-interrupt visual cues.
Intelligence Hypothesis:
Moderate signal(71%)|Because:
rejectedWhat this could not see: No rostering connector data available to verify staffing density
Why 4
ATT-00233
Why 4: The facility layout was grandfathered without ergonomic human factors review.
Intelligence Hypothesis:
Moderate signal(71%)|Because:
rejectedWhat this could not see: No rostering connector data available to verify staffing density
Why 5Identified Root Cause
ATT-00234
Why 5 (Root Cause): Capital refurbishment guidelines lacked mandatory patient safety engineering criteria.
Intelligence Hypothesis:
Moderate signal(71%)|Because:
rejectedWhat this could not see: No rostering connector data available to verify staffing density