Work Through a 5 Whys Order Quality Miss
Use 5 Whys to identify a changeable root condition behind a delayed radiology exam.
CTA is delayed 41 minutes because contrast allergy status is missing at patient arrival. 5 Whys: move from event to evidence-based root condition, then choose a countermeasure that changes the condition. The common trap is stopping at the last person who touched the case. That creates reminders instead of controls. Why 1 Why was CTA delayed? Allergy status was missing when the patient arrived. This names the immediate cause but not the system condition. Why 2 Why was allergy status missing? The external order did not require that field. The chain moves upstream to order intake. Why 3 Why did…
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