Bow Tie Analysis

Part 1 A reference is provided for this week’s assignment, which includes an illustration of the application of bow-tie methodology.  The reference for the final assignment is as follows: /content/enforced/266279-013930-01-2182-OL4-7981/Application of Bow-Tie Methodology.pdf  This approach is also beneficial in addressing complex healthcare issues and conducting RCAs in different settings.  1.  How can the bow-tie approach assist in addressing complex healthcare incidents? Do you prefer the bow-tie approach over another approach? Why?  Helpful Hints: One approach is not better than another.  Every organization establishes its own set of parameters for conducting RCAs and may use a multitude, or culmination, of tools.  This question is a critical thinking question and depending on your professional healthcare goals, maybe something that you may utilize in the future.   Part 2: Please Read Carefully: Topic Selection: Select a topic for the bow-tie analysis.  Examples of Topic Areas: 1. Child abduction from a hospital unit or infant discharge to the wrong person. 2. Medication error in a selected healthcare facility such as providing the wrong dosage of medication or the wrong medication to a patient. 3. Adverse event in a selected healthcare facility such as surgery performed on the wrong body part or retention of a foreign object during the surgery. 4. A specific documentation deficiency, or practice, such as not maintaining a care plan in a selected healthcare setting, or failure to follow range orders. 5. Violations of a selected Joint Commission standard, or other regulatory body regulation, such as noncompliance with Life Safety protocols in a selected healthcare setting related to fire drills, Environment of Care issues related to proper oxygen storage, or dietary deficiencies related to proper temperatures of meals delivered to patients’ rooms. 6. Any other similar negative outcome, adverse event, or sentinel event, in a selected healthcare industry that the student feels is important to examine within a bow-tie analysis.   1.  Discussion: One page minimum, clearly articulating the critical incident, adverse event, or sentinel event, with a background on the topic that will be discussed.  a. Important information to include in the 1-page discussion: Information on the situation for conducting a root cause analysis (RCA) using the quality improvement tool of the bow-tie analysis, which could describe the parties involved in the incident (healthcare setting’s leadership, clinical team, patients, or other parties); what was being examined (topic selection information); why was the information being examined; what was the issue being examined based on the topic selection information; potential ways the bow-tie analysis can support in resolving the issue; and an overview of how the bow-tie analysis was conducted.    b. Clear & Concise Information: The discussion on the event must allow for a clear understanding regarding the situation that was applied for the bow-tie analysis. c. Approaches for the Discussion Aspect of the Task: Students may elect to present this information in a variety of ways.  Examples: Standard paragraph form for the one-page minimum discussion; an introduction with a table of the items listed above with a closing paragraph; information presented in paragraph form followed by bulleted items listed above; or provide any other applicable discussion approach that demonstrates sound knowledge for all the required aspects for this task. 1.  Illustration: Conduct the bow-tie analysis: 1-page illustration of a completed bow-tie analysis. a. The bow-tie analysis should be reflective of the information provided within the discussion aspect of this task.  b. Bow-Tie Examples: Refer to reading materials for reference on how to conduct a bow-tie analysis or obtain examples from the library. c. Student’s Original Work: Copyrighted pictures, pictures from the internet, scanned images or other images are NOT allowed.  The bow-tie analysis must be the student’s original work regarding the task that is being performed.  Students may elect to complete the analysis in a sperate document or complete the analysis on the same submission as the discussion aspect.  Students that have taken this course previously have elected to use a secondary document such as Excel, Publisher, Word, or PowerPoint to show their illustration.  The illustration must be legible for full evaluation, meaning the illustration needs to clear enough to be read and examined for the bow-tie analysis.   Minimum 2 External Sources:  Ensure at least two scholarly resources are provided and supported throughout the paper for supporting evidence.  Students may elect to use the references provided within the final week or select other scholarly sources for the discussion.

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