INC-2026-0049·General Medicine (Ward 4C)
Root Cause Analysis: Patient fall event (Unassisted mobilization) in Ward 4C
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
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Why 1: The prescribed protocol was not completed as chartered.
Why 2
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Why 2: Staff were interrupted by an urgent bedside emergency alarm during preparation.
Why 3
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Why 3: The physical medication prep area lacks isolation barriers or do-not-interrupt visual cues.
Why 4
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Why 4: The facility layout was grandfathered without ergonomic human factors review.
Why 5Identified Root Cause
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Why 5 (Root Cause): Capital refurbishment guidelines lacked mandatory patient safety engineering criteria.