Use 5 Whys without stopping at blame
Use 5 Whys to trace a laboratory defect beyond the last person involved and into a controllable process condition.
A critical calcium result was verified at 08:12 but not called until 08:54. The patient was on a monitored unit. The bench tech says they forgot during analyzer maintenance. 5 Whys: keep asking why the failure happened until the team reaches a controllable process condition, not merely the last person involved. The common trap is stopping at "the technologist forgot." That answer may be true and still too shallow to prevent recurrence. Why 1 Why was the critical value called late? The technologist did not see the pending critical call alert after verification. Start with the direct mechanism, not judgment.…
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