Most of the time in an investigation, we rely on Why? questions to connect causes and build a Cause Map™ diagram. Why was our goal negatively impacted? Why did that occur? Each answer links to the next, creating the chain of cause-and-effect that explains what happened.
But sometimes, asking why leads to an answer that is too broad. Labels like “equipment failure” and “human error” don’t reveal much about what actually happened. That’s when asking How? can help. By asking how, you get three important benefits:
The connecting details you reveal with How? questions are critical not only for developing a thorough analysis, but also for communicating that analysis and the solutions to your target audience.
In 1995, Willie King had the wrong foot amputated. It’s a case that still gets referenced nearly 30 years later because it shows just how far an error can travel once it’s embedded in the work process.
If we start with the basics, the patient was harmed because his left foot was amputated. Why was his left foot amputated? Because the surgical team believed it was the correct foot. Why did they believe that? Because the left foot had been prepped and draped. Why was the left foot prepped and draped? Because of a scheduling error.
Wrong-Site Amputation 5-Why Cause Map™ Diagram
The 5-Why above is accurate, but “Scheduling error” is still a generic label. It doesn’t describe the work process or give us many options for solutions. This is where switching to a how question opens things up. How did a scheduling error result in the wrong foot being prepped?
Asking How Expands Cause Map™ Diagram
Now we can see the sequence of steps that carried the wrong information from the computer system all the way into the operating room. Asking how sets you up to begin mapping out the work process to see how tasks, tools, and communication link together. If you want to see the process map for this case example, take a look at Blame Solves Nothing: Revisiting the Willie King Wrong-Site Amputation.
Asking How? requires me to dig into the process in order to reveal the causes that go in between "Left foot prepped for surgery" and "Scheduling error." If the analysis stops at “Scheduling error,” the most likely recommendation is to be more careful. But that type of response rarely reduces risk in a meaningful way. This is why asking how is so powerful: it strengthens the analysis and brings the work process into view.
When the work process is visible, more specific and useful solutions emerge. A hospital might add a verification step when information is first entered into the scheduling system. They could require confirmation when the schedule is posted to the operating room board. The surgical team could verify the site with the patient before prep begins. Each of these is tied to a real step in the work process, which makes the solution more practical to implement, measure, and sustain.
That’s the real strength of combining Why? and How? questions. Asking why keeps the analysis moving through the chain of cause-and-effect. Asking How? slows things down and uncovers the work process behind a vague cause. Together, they create both the structure and the detail needed to reduce risk.
The next time you’re in a discussion and you get a generic answer, try asking how. For example, if someone says, “The wrong patient record was used,” asking, “How did that happen?” invites a description of the steps that led to the error: how the record was pulled, how the schedule was confirmed, and how the information was communicated between teams. Each answer uncovers the sequence of actions and decisions that shaped the outcome.