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

• DOI: 10.1097/pts.0b013e318288a476
• Publication Date: 2013-08-20T12:19:40Z
• Authors: Monika C. Kerckhoffs; Alexander F. van ...; Jan M. Binnekade; Dave A. Dongelmans
• Keywords: Bow tie

Objectives To improve patient safety, potential critical events should be analyzed for the existence of preventive barriers. The aim this study was to prospectively identify existing and missing barriers using Bow-Tie model. We expected that analysis these would lead feasible recommendations safety in daily care. Methods Multidisciplinary teams doctors nurses on a 28 bed ICU conducted study. performed intrahospital transportation, unplanned extubation, communication, which led 9 events. For each event, threats consequences were defined placed diagram. Then, determined, ways prevent threat or limit consequences. as feasibility. Results Intrahospital transportation: hazard 7 events, 52 but implementable 8 practical recommendations. example, pretransportation checklist. Unplanned extubation: revealed 15 (of total 32) 22 One them optimizing treatment delirium. Communication: showed 21 barriers, which, 12 implement. These to7 such need cosign after handover patient. Conclusions Prospective risk model proved usable Many seemed implement improvements safety.