{
  "schema": "vedokrok.public-item.v1",
  "release_id": "MHC-RPUB-20260920-75ad787a",
  "url": "/knowledge/follow-the-why-chain-until-the-cause-becomes-changeable",
  "id": "MHC-D-RESEARCH-0730",
  "version": "0.1.0",
  "title": "Follow the why-chain until the cause becomes changeable",
  "summary": "Do not stop at a label that merely renames the event.",
  "kind": "protocol",
  "body": "Ask why the observed event was possible, then ask why about the answer while the chain remains evidence-based. Stop when you reach a factor the system can change, when the chain branches, or when evidence runs out. Record branches instead of forcing one linear root cause.",
  "limits": [
    "Five Whys is a prompt for inquiry, not a guarantee of one root cause. Complex failures commonly have interacting causes."
  ],
  "topics": [
    "union-learning-from-decisions-and-errors"
  ],
  "intents": [],
  "source_ids": [
    "RS-C63447C9710D56FD"
  ],
  "evidence": [
    {
      "claim": "Modern RCA guidance emphasizes system-level contributing factors and sustainable corrective actions rather than stopping at individual blame or documentation.",
      "source_id": "RS-C63447C9710D56FD",
      "role": "supports",
      "note": "AHRQ discusses healthcare safety. The corpus transfers the system-design logic cautiously to ordinary work.",
      "locator": "Introduction; RCA2; action hierarchy discussion"
    },
    {
      "claim": "Five Whys is used in RCA2 to extend a causal chain beyond an immediate event description.",
      "source_id": "RS-C63447C9710D56FD",
      "role": "supports",
      "note": "Repeated 'why' questions can oversimplify branching causes; answers still need evidence.",
      "locator": "Discussion of event mapping and Five Whys"
    }
  ],
  "use_when": [
    "The immediate explanation is a label such as human error, missed step, bad data or process deviation."
  ],
  "avoid_when": [
    "Five Whys is a prompt for inquiry, not a guarantee of one root cause. Complex failures commonly have interacting causes."
  ],
  "example": "Wrong field mapped → template used an old label → template had no version check → add a version gate at upload.",
  "check": "The final factor suggests a concrete control and each causal link has evidence or is marked as a hypothesis.",
  "steps": [
    "Is this answer more than a label?",
    "What evidence supports the next link?",
    "Did the chain split into multiple contributors?",
    "Is the current factor changeable?",
    "Are we now guessing?"
  ],
  "sources": [
    {
      "id": "RS-C63447C9710D56FD",
      "title": "The Evolution of Root Cause Analysis",
      "url": "https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis"
    }
  ],
  "relations": [
    {
      "from": "MHC-D-RESEARCH-0730",
      "to": "MHC-D-RESEARCH-0731",
      "type": "alternative",
      "url": "/knowledge/fan-possible-causes-out-before-narrowing-them"
    }
  ],
  "collections": [
    {
      "id": "RC-D475A7021FD981F0",
      "title": "Turn mistakes and outcomes into changes you can verify",
      "url": "/collections/turn-mistakes-and-outcomes-into-changes-you-can-verify"
    }
  ]
}