> The real problem with ‘5 whys’ is not how it is used in RCA [root cause analysis], but rather that it so grossly oversimplifies the process of problem explora

> The real problem with ‘5 whys’ is not how it is used in RCA [root cause analysis], but rather that it so grossly oversimplifies the process of problem exploration that it should not be used at all. It forces users down a single analytical pathway for any given problem, insists on a single root cause as the target for solutions, and assumes that the most distal link on the causal pathway (the fifth ‘why’) is inherently the most effective and efficient place to intervene. ^ That's the best section of the article. Also, I think the causal tree they included for an incident at a hospital (patient received the wrong medicine) is fascinating (see Figure 1; I included a direct link to the JPG[0] below). They explored one chain of causal subtrees to a depth of 11, and the total number of nodes is 78 (although some subtrees are repeated - it would have been better as a DAG[1] instead of a tree). It exposes significant policy and work culture issues at the facility and gives the reader a sense that they already know a lot about what it must be like for the nurses who work there. [0] https://qualitysafety.bmj.com/content/qhc/26/8/671/F1.large.jpg https://qualitysafety.bmj.com/content/qhc/26/8/671/F1.large.... [1] https://en.wikipedia.org/wiki/Directed_acyclic_graph https://en.wikipedia.org/wiki/Directed_acyclic_graph