Improving Patient Safety in the ICU by Prospective Identification of Missing Safety Barriers Using the Bow-Tie Prospective Risk Analysis Model

Kerckhoffs, Monika C.; Sluijs, Alexander F. van der; Binnekade, Jan M.; Dongelmans, Dave A.

doi:10.1097/pts.0b013e318288a476

Cited by 23 publications

(29 citation statements)

References 12 publications

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“…So the main function of BTA can perhaps be viewed as an effective risk communication tool to link together guidewire retention events with their contributing factors, controls, and consequences and to highlight both existing and missing/possible barriers. As such, it could be seen as a prospective rather than merely reactive medical safety management tool …”

Section: Discussion: Comparison Of the Bta And Stpa Approachesmentioning

confidence: 99%

“…(27)(28)(29) Recently, bow-ties have also been successfully used in medical safety. (7,30,31) Equally, BTA can show both existing controls and potential/recommended controls for hazards as well as highlighting where gaps in control may exist. (7) One of the particular strengths of BTA is that it provides a quickly understood overview of the risk controls linked to initiating events.…”

Section: Bow-tie Analysismentioning

confidence: 99%

“…BTA is an increasingly popular approach often employed in high‐hazard industries such as mining and aviation . Recently, bow‐ties have also been successfully used in medical safety . Equally, BTA can show both existing controls and potential/recommended controls for hazards as well as highlighting where gaps in control may exist .…”

Section: Introductionmentioning

confidence: 99%

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A Comparison of the Bow‐Tie and STAMP Approaches to Reduce the Risk of Surgical Instrument Retention

et al. 2017

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Although relatively rare, surgical instrument retention inside a patient following central venous catheterization still presents a significant risk. The research presented here compared two approaches to help reduce retention risk: Bow-Tie Analysis and Systems-Theoretic Accident Model and Processes. Each method was undertaken separately and then the results of the two approaches were compared and combined. Both approaches produced beneficial results that added to existing domain knowledge, and a combination of the two methods was found to be beneficial. For example, the Bow-Tie Analysis gave an overview of which activities keep controls working and who is responsible for each control, and the Systems-Theoretic Accident Model and Processes revealed the safety constraints that were not enforced by the supervisor of the controlled process. Such two-way feedback between both methods is potentially helpful for improving patient safety. Further methodology ideas to minimize surgical instrument retention risks are also described.

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Section: Discussion: Comparison Of the Bta And Stpa Approachesmentioning

confidence: 99%

Section: Bow-tie Analysismentioning

confidence: 99%

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A Comparison of the Bow‐Tie and STAMP Approaches to Reduce the Risk of Surgical Instrument Retention

et al. 2017

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“…(Alderman, 2012) Adverse events in surgical contexts (Healey et al, 2010) (Bohomol & Tartali, 2013) Adverse events in the continuity of care (Mistry et al, 2010) ( Kerckhoffs et al, 2013) Adverse events related with medication (Symons et al, 2013) (Cox & Butt, 2012) …”

Section: Resultsmentioning

confidence: 99%

Clinical Communication and Adverse Health Events: Literature Review

Ferreira¹,

Brás²,

Barbieri³

2016

European Proceedings of Social &Amp; Behavioural Sciences

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Health institutions have an increased risk of occurrence of errors due to their diversity, specificity and volume of services, representing a great concern for health professionals whose main function is to protect the health and lives of their patients. We intend to identify a body of evidence, that shows what the most common adverse events are and what adverse events potentially arise from clinical miscommunication. We made an integrative literature review using the keywords "Adverse Events", "Patient Safety", "Communication". An inquiry on databases of PubMed, Web of Science, Scielo and CINAHL, in articles published between January 2010 and March 2016, was made; all available in Portuguese and English. Of the 216 articles that emerged, we selected eight that answered the research questions: what are the most common adverse events that have their origin in communication errors? Analyzing the selected studies, it appears that the most common adverse events arise in the context of obstetrics and pediatrics, in surgical contexts, in the continuity of care and related medication. Patient safety should be seen as a key component of quality in health care, with good management of the risk of fundamental error for the promotion of this security. The knowledge and understanding that communication failures are one of the main factors contributing to the occurrence of errors in the context of health care, allows the subsequent development of strategies to improve this process and thus ensure safer healthcare.

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“…For prospective risk analysis, there are several other methods. Examples are the bow-tie method and the health-care failure mode and effect analysis (HFMEA) [49–51]. …”

Section: Introductionmentioning

confidence: 99%

The impact of changes in intensive care organization on patient outcome and cost-effectiveness—a narrative review

et al. 2017

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The mortality rate of critically ill patients is high and the cost of the intensive (ICU) department is among the highest within the health-care industry. The cost will continue to increase because of the aging population in the western world. In the present review, we will discuss the impact of changes in ICU department organization on patient outcome and cost-effectiveness. The general perception that drug and treatment discoveries are the main drivers behind improved patient outcome within the health-care industry is in general not true. This is especially the case for the ICU department, in which the past decades’ organizational changes were the main drivers behind the reduction of ICU mortality. These interventions were at the same time able to reduce cost, something which is rare for drug and treatment discoveries. The organization of the intensive care department has been changed over the past decades, resulting in better patient outcome and reduction of cost. Major changes are the implementation of the “closed format” and electronic patient record. Furthermore, we will present possible future options to improve the organization of the ICU department to further reduce mortality and cost such as pooling of dedicated ICU into mixed ICU and embedding business strategies such as lean and total quality management. Challenges are ahead as the ICU is taking up the largest share of national health-care expenditure, and with the aging of the population, this will continue to increase. Besides future improvements of organizational structures within the ICU, the focus should also be on the implementation of and compliance with proven beneficial organizational structures.

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Improving Patient Safety in the ICU by Prospective Identification of Missing Safety Barriers Using the Bow-Tie Prospective Risk Analysis Model

Abstract: Prospective risk analysis using the Bow-Tie model proved usable to identify existing and missing barriers for potential critical events. Many missing barriers seemed feasible to implement and led to practical recommendations and improvements in patient safety.

Cited by 23 publications

References 12 publications

A Comparison of the Bow‐Tie and STAMP Approaches to Reduce the Risk of Surgical Instrument Retention

A Comparison of the Bow‐Tie and STAMP Approaches to Reduce the Risk of Surgical Instrument Retention

Clinical Communication and Adverse Health Events: Literature Review

The impact of changes in intensive care organization on patient outcome and cost-effectiveness—a narrative review

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