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Bowtie risk templates

Bowtie — Wrong-Dose Medication on an Acute Ward

Ward-level bowtie for injectable medicines: 60 dosing errors a year reduced to 5.04 wrong doses reaching a patient, ranking the bedside barcode scan twice as critical as the smart-pump drug library and leaving 97.9% of the inherent harm removed.

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Wrong-dose medication administered — acute wardHAZARDHigh-risk injectable medicines held on the wardTHREATSPREVENTIVE BARRIERSRECOVERY BARRIERSCONSEQUENCESClinician overrides the alertwithout reading itHard stop on insulin andopioid alertsElectronic prescribingwith dose-range checking85% · detectionPharmacist clinical screenbefore dispensing70% · detectionScanner batteries flat on thenight trolleyTall-man lettering andsegregated storage bins55%Barcode scan of theampoule at the bedside80% · detectionDouble check performed as arubber stampMonthly audit of double-checkcomplianceSmart pump drug librarywith soft and hard limits75% · controlSecond-nurse independentdouble check60% · detectionEarly warning scoreobservations every 4 hours60% · detectionAntidote stocked on theward for the top ten drugs70% · recoveryRapid response team calledon deterioration65% · recoveryDuty of candour and earlysettlement process40% · recoveryIncident reporting feedingthe safety huddle30% · recoveryPrescription writtenwith a tenfold dosingerror12/yr → 0.54/yrLook-alike sound-alikeampoule picked from thecupboard30/yr → 2.7/yrInfusion pumpprogrammed with thewrong rate18/yr → 1.8/yrSevere patient harmrequiring criticalcaresev 5 · risk 3.02Prolonged admissionwith reversible harmsev 3 · risk 5.29Litigation andregulatorynotificationsev 2 · risk 4.23Wrong doseadministered toa patient5.04/yrtop-event frequencyTop event5.04/yrinherent 60/yrResidual risk12.55inherent 600Risk reduction97.9%threat side 91.6%Barriers113 threats · 3 consequencesDominant threatLook-alike sound-alike ampoule picked f…53.6% of the top eventResidual risk 12.55 against an inherent 600 — the barriers remove 97.9% of it. 2 things are probably not what was meant — every path and every escalation factor was checked.Barrier criticality — residual risk if that one barrier were removed1. Barcode scan of the ampoule at the bedside+26.89 ×3.12. Smart pump drug library with soft and hard limits+13.45 ×2.13. Rapid response team called on deterioration+9.83 ×1.84. Tall-man lettering and segregated storage bins+8.22 ×1.75. Electronic prescribing with dose-range checking+7.62 ×1.66. Antidote stocked on the ward for the top ten drugs+7.06 ×1.6FindingsConsequence "Prolonged admission with reversible harm" rests on ONE barrier. Defence in depth is the claim a bowtie is drawn to make, and a single barrier is a single point of failure: the day it fails is the day the consequenc…Escalation factor "Scanner batteries flat on the night trolley" degrades barrier "Barcode scan of the ampoule at the bedside" and nothing is holding it off. The 80% credited to that barrier — and every figure computed from it —…Each of the 3 consequences is credited the full top-event frequency of 5.04/yr — the model here is that one top event produces all of them, so the residual score of 12.55 adds 3 outcomes to one event. That is right when they ha…

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# Flat dialect: barriers attach to the threat above them, escalation
# factors to the barrier above them, controls to the escalation factor.
title "Wrong-dose medication administered — acute ward"
hazard "High-risk injectable medicines held on the ward"
top "Wrong dose administered to a patient"
unit "/yr"

threat "Prescription written with a tenfold dosing error" likelihood: 12
  barrier "Electronic prescribing with dose-range checking" effectiveness: 0.85 type: detection
    escalation "Clinician overrides the alert without reading it"
      control "Hard stop on insulin and opioid alerts"
  barrier "Pharmacist clinical screen before dispensing" effectiveness: 0.7 type: detection

threat "Look-alike sound-alike ampoule picked from the cupboard" likelihood: 30
  barrier "Tall-man lettering and segregated storage bins" effectiveness: 0.55
  barrier "Barcode scan of the ampoule at the bedside" effectiveness: 0.8 type: detection
    escalation "Scanner batteries flat on the night trolley"

threat "Infusion pump programmed with the wrong rate" likelihood: 18
  barrier "Smart pump drug library with soft and hard limits" effectiveness: 0.75 type: control
  barrier "Second-nurse independent double check" effectiveness: 0.6 type: detection
    escalation "Double check performed as a rubber stamp"
      control "Monthly audit of double-check compliance"

consequence "Severe patient harm requiring critical care" severity: 5
  barrier "Early warning score observations every 4 hours" effectiveness: 0.6 type: detection
  barrier "Antidote stocked on the ward for the top ten drugs" effectiveness: 0.7 type: recovery

consequence "Prolonged admission with reversible harm" severity: 3
  barrier "Rapid response team called on deterioration" effectiveness: 0.65 type: recovery

consequence "Litigation and regulatory notification" severity: 2
  barrier "Duty of candour and early settlement process" effectiveness: 0.4 type: recovery
  barrier "Incident reporting feeding the safety huddle" effectiveness: 0.3 type: recovery