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PSNet: Patient Safety Network
Journal Article

The problem with the '5 whys.'

Card AJ. BMJ quality & safety. 2017;26:671-677.

Investigation of incidents in complex systems can be hindered by time limitations, lack of follow-up, and incomplete resolution. This commentary discusses a commonly used tool to identify root causes of problems. The author highlights its value as a teaching tool but notes that its use for root cause analysis in health care may be misguided as it tends to simplify complex problems and limit understanding of how processes fail.