Healthcare question regarding a bow tie analysis of a critical incident

Feb 3rd, 2012
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Academy of Chinese Culture and Health Sciences
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In my class we examined the Joint Commission’s framework for root cause analysis of sentinel Incidents in health care organizations. For purposes of this project, a critical incident is a key occurrence, but it is not a sentinel event. A bow-tie analysis places the critical incident at the center of the framework and identifies in graphic format the root cause leading up to the incident on the left side of the critical incident. On the right side of the incident, key preventive measures are graphically represented.

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Joint Commission's framework for cause analysis of sentinel Incidents in health care organizations & bow-tie analysisEvery single day, serious adverse events occur in healthcare systems around the world resulting in damage to tens of thousands of people yearly Institute of Medicine. Home care isn't immune. Lack involving staff supervision, transmission, coordination of care, reduced ability to interact within double investigations, lack of care environment control, along with a heightened reliance in patient and family members cooperation are scenarios unique to house care that help with serious negative activities.The Joint Payment represents a sentinel celebration as "an unforeseen occurrence involving death or serious bodily or psychological personal injury, or the risk thereof" (The Shared Commission, 2012, s. 1). "Risk thereof" means incidents for which in turn a recurrence would involve an important risk of serious adverse outcome. The Joint Payment (2012) further describes reviewable sentinel activities as occurrences that lead to "an unanticipated death or major permanent reduction of function not relevant to the natural length of the patient's condition or underlying condition" (p. 1). Continuous reduction of function may consider sensory, motor, physiologic, or intellectual incapacity requiring continued therapy or change inside lifestyle not present from the beginning of care.Your Joint Commission designates activities as sentinel simply because requir

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