Bow & Tie analysis for Medication Safety
MEDICATION SAFETY 2
Bow & Tie analysis for Medication Safety
Medical practitioners use various prescriptions to treat different infectious illnesses, deal
with the symptoms of continual ailments, and relieving pain. Generally, medicines are safe is
used as indicated by the medical practitioner or as described in the labeling. Nonetheless, there
are certain risks associated with different prescriptions. Recent statistics indicate that adverse
medication events have resulted in more than 700,000 visitations to the emergency departments
of different sanatoriums within the United States (Current awareness: Pharmacoepidemiology
and drug safety, 2010). This entails the injuries acquired from the use of prescriptions. Most
analysts indicate that such adverse medication events are avoidable. Medical personnel and
ailing individuals can aid in reducing the risk of injuries from prescriptions by comprehending
the key concepts of medication safety. Such educational programs ought to be conducted in
different forums by focusing on various population groups in terms of age brackets, gender, and
health conditions.
In order to enhance medication safety, it is important to systematically evaluate the
noteworthy prescription errors in addition to determining the feasible causes of such unpleasant
events. The Bow-Tie model is an effective risk analysis mechanism that can be used in the
healthcare subsector with the main aim of effectively analyzing the risks, possible causes, and
impacts of various adverse prescription events. In the hospital setting, some of the risk factors
associated with medication safety include administration faults of injectable medicines (Phipps,
Noyce, Walshe, Parker & Ashcroft, 2011). This may be prevented by using an electronic system
to crosscheck the prescriptions. This prevention measure may also aid in avoiding adverse
prescription events caused by the placement of medication stickers attached to the prescription
account of the wrong individual. Another risk factor that is bound to cause adverse prescription
MEDICATION SAFETY 3
events as indicated through the Bow-Tie analysis is the confusion that occurs when transferring
prescription information between different sanatoriums or wards (Workman, LaCharity &
Kruchko, 2011). However, such a situation may be dealt with by using an electronic information
exchange program.
MEDICATION SAFETY 4
Bow-Tie Diagram
UNDERLYING
CAUSES
Surgeons giving
priority to ailing
individuals over
the timely
prescription of
medications
An extremely
busy schedule
for resident
surgeons
A large
percentage
of surgeons
are often not
available in
hospital
wards
Little consideration
made on structural
aspects aimed at
enhancing
awareness among
nursing personnel
regarding
prescription errors
and the reported
adverse medication
events
Medical
doctors do
not
recommend
medication
to an ailing
individual
who is
newly
admitted
into the
sanatorium
Nurses make
sure if the
suitable
medications
have been
stipulated
(warning
function)
INITIAL
ERROR
PREVENTIVE
BARRIER
TOP EVENT:
Delays or lack of
medication orders at
a hospital’s surgery
subsector
Nurses
recomm
end
prelimin
ary
medicati
on
orders
(unperm
itted)
The ailing
individual
is aware
of risks
associate
with
prescripti
ons and
cautions
the nurse
Surgeons requests
medical
practitioners of
internal
medication to
recommend drugs
at the surgery
department
RECOVERY
MEASURES
Effects of
medication
errors vary in
severity from
one patient to
another
(delayed
management
of morbidities)
Complains
from the ailing
individuals
CONSEQUENCE
S
MEDICATION SAFETY 5
References
Current awareness: Pharmacoepidemiology and drug safety. (April 01, 2010).
Pharmacoepidemiology and Drug Safety, 19, 4.)
Phipps, D., Noyce, P., Walshe, K., Parker, D., & Ashcroft, D. (January 01, 2011). Risk-based
regulation of healthcare professionals: What are the implications for pharmacists?.
Health, Risk & Society, 13, 3, 277-292.
Workman, M. L., LaCharity, L. A., & Kruchko, S. C. (2011). Understanding pharmacology:
Essentials for medication safety. St. Louis, Mo: Elsevier/Saunders.