Investigating the use of Bowtie Analysis as a Prospective Risk Assessment technique in healthcare
Event Type
Oral Presentations
TimeWednesday, April 142:20pm - 2:40pm EDT
LocationPatient Safety Research and Initiatives
DescriptionThere is a need to close the gap in the understanding of barrier management issues affecting patient safety. There is however limited engagement in healthcare with the kinds of proactive approaches to risk assessment or Barrier Management widely used in other industries.
Bowtie Analysis (BTA) has previously been shown to have potential as a straightforward approach to proactively assessing risk in healthcare. The rapid growth in the use of BTA as a risk management tool in recent years across many industries, has been driven largely by what is seen as the conceptual simplicity of the approach and the visual representation of the analysis. When it is done properly, BTA can provide a rich understanding of the controls that are expected to be in place to protect against incidents, how they can fail, and how they need to be implemented, supported and managed. And it can do so without having to make any assumptions about the mechanisms or nature of accident causation.
Over the past 4 years, NHS Education for Scotland (NES) has been exploring the potential use of BTA as a prospective approach to risk assessment in healthcare. A particular emphasis has been on the training and support likely to be needed for existing healthcare professionals to conduct Bowtie Analysis in compliance with recognised industry best-practice.
In a recent study, existing healthcare professionals were recruited to undergo training on BTA. Following training, and drawing on guidance prepared by NES, and a small amount of support from a specialist, three trainees led analyses into significant risks: misadministration of Gentamicin; unknown development of Acute Kidney Injury (AKI); and disposal of medical devices containing patient identifiable information (PII). Subjective assessments of the analyses against indicators of industry best-practice suggested the analyses were of good quality. In each case, using BTA led to a deeper understanding of the issues and a more thorough understanding of the risks and what was needed to control them than would have been the case if ‘normal practice’ had been followed.
The study concluded that, given access to suitable guidance and a small amount of specialist support, individuals from a wide range of backgrounds should be able to facilitate a BTA to a reasonable quality with a relatively short training intervention.