Here’s a medical example of 5-Whys. Tell me what you think…
A patient had the wrong leg amputated
1. Why Patient gave consent for amputation the night before the proposed
surgery to Registrar (who was not going to undertake procedure).
2. Why Amputation site marked with a biro (wrong leg).
3. Why Registrar unaware of hospital policy on amputation sites
being marked with a skin pencil and with 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.
good Problem statement, Good attempt, be cautious when using 5why alone it has a huge potential to lead you down the wrong patyh. The tool should only be used after all contributing causes have been indentified. For instance start with a cause and effect diagram to brainstorm then use the 5why to flush out the root causes. The fact that no one asked may be only one root cause of many (I would bet on that).
A down and dirty drill down is what you get from the 5 “why’s”. But it drills down usually a small pice at a time, ie:
Why: Patient gave consent for amputation the night before the proposed
surgery to Registrar (who was not going to undertake procedure).
Why does this happen? We allow patients to give consents to people not involved in the case.
Why do you allow it? It takes weight off of the anesthesiologist and surgeon
Answer: don’t allow non-clinicians to perform the consent
Or: Amputation site marked with a biro (wrong leg).
Why: we’ve always marked sites with biro’s
Why: no one ever had an issue with it
Why: because the director said it was ok… OK, I admit it: it was my fault!!!! I work for Biro in my spare time and get a kick back!!!
Problem solved except that the why’s can only go so far. You drill down on one issue. In the case of the wrong leg, it has multiple facets and Paul is right to say that the 5 why’s alone won’t drill down enough of the various layers.
Entirely the wrong question; the patient MUST sign a consent form to perform a surgery; but the patient is NOT responsible for designation of the surgical procedure; the surgeons consultation notes MUST be in the ORclearly stating the patient condition and which leg is to be amputated.
It could have been the wrong patient, a patient with a tatoo, or the right leg depends on face-up or face-down orientation of the patient.
The surgeon is responsible to ensure that HIS notes match the patient , by name and hospital arm bracelet, and pre-surgical pre-operative draping is consitent with the case notes. Better yet; require the surgeon to mark with shin pencil in consultation.
Consider a barrier, use hospital bracelet on ankle , do not remove , on the good leg.
The main purpose of an investigation is not to find out where people went wrong – It is to understand why their assessment and action made sense. Based on the new thinking of the logic of failure re-evaluate your 5Why’s – You should be able to 100% eliminate the re-occurrence. The Amputation of the wrong leg.
I’m not sure response 1 would be the first “why.” It looks like they were trying to identify the cause. #2 would be my first why response. I wonder why someone NOT related to the procedure and not trained in the marking procedure would be marking the leg for surgery. (Obviously, I dont work in a hospital.)
I like all of the responses above.
Great article. There is something to think about. thanks.