In Week 7, the class examined the Joint Commission’s framework for root cause analysis of sentinel Incidents in health care organizations. For purposes of this project, a critical incident is a key occurrence, but it is not a sentinel event. A bow-tie analysis places the critical incident at the center of the framework and identifies in graphic format the root cause leading up to the incident on the left side of the critical incident. On the right side of the incident, key preventive measures are graphically represented. In one image, you will capture the incident (at the center), the causes for failure in quality, and (on the right) preventive measures a manager can put in place to stop this failure from happening in the future. The final graphic will appear as a bow-tie. The instructor will provide an example. Each student will select a critical incident for approval by the instructor.
This project must include a cover page, a one-page explanation, a one-page graphic image (bow-tie analysis), and references.
SAMPLE ANSWER
Bow & Tie analysis for Medication Safety
Medical practitioners use various prescriptions to treat different infectious illnesses, deal with the symptoms of continual ailments, and relieving pain. Generally, medicines are safe is used as indicated by the medical practitioner or as described in the labeling. Nonetheless, there are certain risks associated with different prescriptions. Recent statistics indicate that adverse medication events have resulted in more than 700,000 visitations to the emergency departments of different sanatoriums within the United States (Current awareness: Pharmaco epidemiology and drug safety, 2010). This entails the injuries acquired from the use of prescriptions. Most analysts indicate that such adverse medication events are avoidable. Medical personnel and ailing individuals can aid in reducing the risk of injuries from prescriptions by comprehending the key concepts of medication safety. Such educational programs ought to be conducted in different forums by focusing on various population groups in terms of age brackets, gender, and health conditions.
In order to enhance medication safety, it is important to systematically evaluate the noteworthy prescription errors in addition to determining the feasible causes of such unpleasant events. The Bow-Tie model is an effective risk analysis mechanism that can be used in the healthcare subsector with the main aim of effectively analyzing the risks, possible causes, and impacts of various adverse prescription events. In the hospital setting, some of the risk factors associated with medication safety include administration faults of injectable medicines (Phipps, Noyce, Walshe, Parker & Ashcroft, 2011). This may be prevented by using an electronic system to crosscheck the prescriptions. This prevention measure may also aid in avoiding adverse prescription events caused by the placement of medication stickers attached to the prescription account of the wrong individual. Another risk factor that is bound to cause adverse prescription events as indicated through the Bow-Tie analysis is the confusion that occurs when transferring prescription information between different sanatoriums or wards (Workman, LaCharity & Kruchko, 2011). However, such a situation may be dealt with by using an electronic information exchange program.
CONSEQUENCES
RECOVERY MEASURES
Bow-Tie Diagram
UNDERLYING CAUSES
Little consideration made on structural aspects aimed at enhancing awareness among nursing personnel regarding prescription errors and the reported adverse medication events
Effects of medication errors vary in severity from one patient to another (delayed management of morbidities)
Complains from the ailing individuals
The ailing individual is aware of risks associate with prescriptions and cautions the nurse
Medical doctors do not recommend medication to an ailing individual who is newly admitted into the sanatorium
Nurses make sure if the suitable medications have been stipulated (warning function)
PREVENTIVE BARRIER
INITIAL ERROR
Surgeons giving priority to ailing individuals over the timely prescription of medications
An extremely busy schedule for resident surgeons
A large percentage of surgeons are often not available in hospital wards
References
Current awareness: Pharmacoepidemiology and drug safety. (April 01, 2010). Pharmacoepidemiology and Drug Safety, 19, 4.)
Phipps, D., Noyce, P., Walshe, K., Parker, D., & Ashcroft, D. (January 01, 2011). Risk-based regulation of healthcare professionals: What are the implications for pharmacists?. Health, Risk & Society, 13, 3, 277-292.
