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) 6^th 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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