INC-2026-0241·Emergency (Triage)
Root Cause Analysis: Patient fall event (Bathroom fall) in Triage
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-00824
Why 1: The prescribed protocol was not completed as chartered.
Intelligence Hypothesis:
Strong signal(82%)|Because:
editedWhy 2
ATT-00825
Why 2: Staff were interrupted by an urgent bedside emergency alarm during preparation.
Intelligence Hypothesis:
Strong signal(82%)|Because:
editedWhy 3
ATT-00826
Why 3: The physical medication prep area lacks isolation barriers or do-not-interrupt visual cues.
Intelligence Hypothesis:
Strong signal(82%)|Because:
editedWhy 4
ATT-00827
Why 4: The facility layout was grandfathered without ergonomic human factors review.
Intelligence Hypothesis:
Strong signal(82%)|Because:
editedWhy 5Identified Root Cause
ATT-00828
Why 5 (Root Cause): Capital refurbishment guidelines lacked mandatory patient safety engineering criteria.
Intelligence Hypothesis:
Strong signal(82%)|Because:
edited