The Bowtie diagram: a simple tool for analysis and planning in anesthesia

Culwick, Martin D; Endlich, Yasmin; Prineas, Stavros

doi:10.1097/aco.0000000000000926

Cited by 10 publications

(10 citation statements)

References 8 publications

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“…Adapted bowtie diagram for perioperative corneal abrasions. 11,12 h: hours; min: minutes; M&M: morbidity and mortality; webAIRS: web-based anaesthesia incident reporting system; NSAIDs: non-steroidal anti-inflammatory drugs.…”

Section: Resultsmentioning

confidence: 99%

Perioperative corneal abrasions: A report of 42 cases from the webAIRS database

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Blamey

et al. 2022

Anaesth Intensive Care

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Corneal abrasions are an uncommon complication of anaesthesia. The aim of this study was to identify potential risk factors, treatment and outcomes associated with corneal abrasions reported to the web-based anaesthesia incident reporting system (webAIRS), a voluntary de-identified anaesthesia incident reporting system in Australia and New Zealand, from 2009 to 2021. There were 43 such cases of corneal abrasions reported to webAIRS over this period. The most common postoperative finding was a painful eye. Common features included older patients, individuals with pre-existing eye conditions, general anaesthesia and procedures longer than 60 minutes. Most cases were treated with a combination of lubricating eye drops or aqueous antibiotic eye drops. The findings indicate that patients who sustain a perioperative corneal abrasion can be reassured that in many cases it will heal within 48 hours, but they should seek earlier review if symptoms persist or deteriorate. None of the cases in this series resulted in permanent harm. Well established eye protective measures are important to utilise throughout the perioperative period, including the time until the patient has recovered in the post-anaesthesia care unit.

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Section: Resultsmentioning

confidence: 99%

Perioperative corneal abrasions: A report of 42 cases from the webAIRS database

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White

Blamey

et al. 2022

Anaesth Intensive Care

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“…Many of these have been summarised in bow-tie diagrams of anaesthesia incidents. 17 , 18 It would have been hoped that with the educational and other resources committed to patient safety in anaesthesia in Australia and New Zealand, the proportion of preventable incidents would have fallen. While we cannot make definitive conclusions about preventability when considering voluntary de-identified incident reports, it appears a continued focus on both human and system factors in the prevention of anaesthesia incidents is warranted and requires re-emphasis.…”

Section: Discussionmentioning

confidence: 99%

A cross-sectional overview of the second 4000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand

Gibbs

Culwick

Endlich

et al. 2021

Anaesth Intensive Care

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This cross-sectional overview of the second 4000 incidents reported to webAIRS has findings that are very similar to the previous overview of the first 4000 incidents. The distribution of patient age, body mass index and American Society of Anesthesiologists physical status was similar, as was anaesthetist gender, grade, location and time of day of incidents. About 35% of incidents occurred during non-elective procedures (vs. 33% in the first 4000 incidents). The proportion of incidents in the various main categories was also similar, with respiratory/airway being most common, followed by cardiovascular, medication-related and medical device or equipment-related incidents. Together these categories made up about 78% of all incidents in both overviews. The immediate outcome was comparable with reports of harm in about a quarter of incidents and a similar rate of deaths (4.7% vs. 4.2%). However, the proportion of patients who had received total intravenous anaesthesia was higher (17.6% vs. 7.7%) and the proportion of patients who received combined intravenous and inhalational anaesthesia was lower (52.3% vs. 58.4%), as was the proportion receiving local anaesthesia alone (1.6% vs. 6.7%). There was a small increase in the number of incidents resulting in unplanned admission to a high dependency or intensive care unit (18.1% vs. 13.5%). It is not clear whether these differences represent trends or random observations. About 48% of incidents were considered preventable by the reporters (vs. 52% in the first 4000). These findings support continued emphasis on human and system factors to promote and improve patient safety in anaesthesia care.

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“…The colour coding of incident evolution -- from a ‘routine’ or ‘safe’ state through a non-routine state to a crisis, and thence through emergency management to a final outcome -- has been incorporated into a Bowtie analysis model [ 41 ▪▪ ]. This diagram consists of five zones and is designed to map and simplify the complexity of crisis and emergency management.…”

Section: Discussionmentioning

confidence: 99%

A proposed system for standardization of colour-coding stages of escalating criticality in clinical incidents

Prineas

Culwick

Endlich³

2021

Current Opinion in Anaesthesiology

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Purpose of review This article proposes a standardized framework for colour-coding states of criticality in clinical situations and their respective escalated responses. Recent findings The first level is a green zone representing a ‘ safe’ space (to proceed) , where any hazards are controlled, latent or undetectable. The second is an amber zone, where hazards are known to be present, but one can proceed with caution and increased vigilance, and where defences are used to prevent escalation to a crisis. In the red phase -- a state of crisis -- a hazard is realized, clear and present. This is a time to decide what actions are required to mitigate the threat. Next, a blue phase refers to a life-threatening emergency , where the system is unstable, harm is evident and compounding upon itself, and immediate rescue action is needed to avert an irreversible outcome. Finally, dark grey represents the aftermath, where the situation has either stabilized or progressed to its final outcome, a time to reflect and learn. Summary A standardized colour-coding system for assessing and responding to escalating levels of criticality has implications for clinical practice and adverse event reporting systems.

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The Bowtie diagram: a simple tool for analysis and planning in anesthesia

Cited by 10 publications

References 8 publications

Perioperative corneal abrasions: A report of 42 cases from the webAIRS database

Perioperative corneal abrasions: A report of 42 cases from the webAIRS database

A cross-sectional overview of the second 4000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand

A proposed system for standardization of colour-coding stages of escalating criticality in clinical incidents

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