Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model.
Approach to Improving Safety
Setting of Care
Conceptually analogous to failure mode and effect analysis, the Bow-Tie method is used to prospectively detect safety hazards. In this study, the Bow-Tie method was used to identify latent safety hazards in intrahospital transport, risk factors for unintentional extubation, and contributors to poor interdisciplinary communication.