bow tie analysis 2

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.

  • Title Page
  • 1 page (double spaced) Page should clearly articulate what the critical incident is and provide background.
  • 1 page Page should include the bow-tie analysis
  • Reference Page (2 references minimum)
  • Written document should conform to American Psychological Association (APA) 6th Edition

Sample incidents

Patient Falls

Medication Overdose

Surgical Items Being Left inside Patient”

Infants being switch at birth in hospitals

Drug interactions and Drug Allergies

Wrong inter-ocular lens and/or power implanted in patient eye.

Medication Error

Pressure Ulcers due to inactivity in nursing homes

Negligent prenatal care

Improper Patient Identification during an invasive/operative procedure

Entering incorrect weight for pediatric patients

Electronic HIPPA violation

Fasciotomy for compartment syndrome

Effects of under dosage of anesthesia

Negligence and physical abuse in nursing homes

Elderly abuse within a nursing home

Patients dying via ambulatory care

Unsterilized surgical tools on patients

Improper dosage and distribution

Risk involve in transporting ICU patients for diagnosis

Drug use during pregnancy

Resident elopement in nursing facilities

NICU medication errors

Language Barriers” and impact on patient health and safety

Medical Billing Errors

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