Narrow Results Clear All
Search results for ""
- Discontinuities, Gaps, and Hand-Off Problems
- Failure Mode Effects Analysis
- Non-Health Care Professionals
PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50.
This failure mode and effects analysis (FMEA) explores factors contributing to near miss and adverse events related to alarm response and provides strategies to prevent monitoring failures.
Journal Article > Study
Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model.
Kerckhoffs MC, van der Sluijs AF, Binnekade JM, Dongelmans DA. J Patient Saf. 2013;9:154-159.
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.