2) Why is prescription wrong? The doctor made an incorrect decision.
3) Why did she make an incorrect decision? She didn’t have the complete information about the patient.
4) Why didn’t she have the complete information? Her assistant omitted a lab report.
5) Why the report wasn’t included? Because the lab technician told the results to the receptionist who forgot to pass it on to the assistant.
Now we see that the solution is to track lab reports better – perhaps by the introduction of a system of some kind. The weakness is in the process, not in an individual. These are the kinds of problems The 5 Whys are a simple, yet very powerful technique for these types of problems.
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