Find the root behind missed treatments

Ms. Alvarez missed three Monday dialysis treatments in six weeks, and the team is tempted to document the issue as nonadherence. Five Whys: ask why until the team reaches an evidence-based process cause it can change. Stopping at the first explanation, such as "she does not care," converts a complex access problem into a character judgment. Why 1 Why did Ms. Alvarez miss Monday treatments? Because she felt too weak and nauseated to travel on Monday mornings. The first answer replaces a label with a patient-reported condition. Why 2 Why was she especially weak on Mondays? Because her weekend fluid…

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