Find the process cause after a wrong-recipient email
Use Five Whys to identify corrective actions after a PHI misdirection incident.
Discharge instructions with PHI were emailed to the wrong person with the same name. Five Whys: symptom -> immediate cause -> process condition -> control gap -> corrective action The common trap is to stop at "the coordinator should be more careful," which leaves the risky address-book workflow unchanged. Why 1 Why did PHI go to the wrong person? The coordinator selected the wrong Michael Chen from auto-complete. This is the visible action, not yet the root process condition. Why 2 Why was the wrong Michael easy to select? The address book showed names and email addresses but no patient…
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