When you are faced with a problem it is useful to stop and ask why five times. It is easy to do but few people do it.
This is a very simple yet very powerful technique. The aim is to ensure that a problem stays solved and never happens again. We do this by identifying and eliminating the root cause of the problem. When the root cause is eliminated the original problem is solved permanently. If the root cause is not dealt with the problem can happen again and again in the future.
Example
The patient was late in theatre
Why?
There was a long wait for a trolley
Why?
A replacement trolley had to be found
Why?
The original trolley's safety rail was worn and had eventually broken
Why?
It had not been regularly checked for wear
Why?
We do not have an equipment maintenance schedule
Setting up a proper maintenance schedule helps ensure that patients will never be late again due to faulty equipment.
If we just repair the safety rail, or even do a one-off safety rail check of all trolleys, the problem will happen again at sometime in the future.
Example
A patient received the wrong medicine
Why?
The prescription was incorrect
Why?
A wrong decision was made by the doctor
Why?
The patient's chart did not contain all the information the doctor needed
Why?
The doctor's assistant had not entered the patient's latest lab test result
Why?
The lab technician had phoned the results through to the receptionist, who forgot to tell the assistant
The root cause here is the absence of a formal system for recording lab test results. Implementing such a system helps ensure that patients will never receive a wrong prescription again due to incomplete lab test data.
