Use Five Whys to investigate a missed medication prompt and identify a stronger system countermeasure.
A substitute aide missed an evening medication prompt for a client who depends on reminder support. Five Whys: move from visible miss to fixable process cause The common trap is stopping at the first person-level answer. Aide forgot may be true, but it rarely explains why the system allowed the miss. Why 1 Why was the prompt missed? The substitute aide did not see it during the evening routine. This names the visible failure without assigning motive. Why 2 Why did the aide not see it? The prompt was buried in narrative notes instead of the task checklist. Now the…
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