February 10, 2010 | Mark Paradies

Medical Example of 5-Whys

Here’s a medical example of 5-Whys. Tell me what you think…

A patient had the wrong leg amputated

1. Why did the patient consent to amputation the night before the proposed

surgery to Registrar (who was not going to undertake the procedure)?

2. Why is the Amputation site marked with a biro (wrong leg).

3. Why is the Registrar unaware of hospital policy on amputation sites

being marked with a skin pencil and the bodily part being fully

visible to Doctor?

4. Why the department had no induction procedures for

new medical staff working in the department?

 5. Why? Because “we’ve never been asked to.”

I’ll give my opinion after others have weighed in.

Root Cause Analysis
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