How can bowties be used in healthcare?
This article unpacks the basics of bowtie analyses – if you’re interested in exploring them, then it’s a good primer even if you’re not from healthcare.
[NB. Full PDF shared under open access licence.]
PS. Check out my new YouTube channel: https://www.youtube.com/@Safe_As_Pod
Extracts:
· “For each hazard identified, it is important to decide whether…appropriate and sufficient controls or contingencies are in place to ensure that the risk is properly controlled’”
· “However, in healthcare controls are rarely subjected to formal scrutiny or assessment to determine whether they are as effective as is believed, whether they are actually in place and functional, or under what conditions they can fail”
· “Bowtie Analysis has suffered both from lack of a strong theoretical foundation and scientific evidence demonstrating its validity as an approach to risk identification and hazard management” [** And not much has changed since 2018 I’d say regarding the published evidence]
· “Each diagram is associated with a specific hazard, i.e. a source of energy or activity with the potential to do harm”
· “For each hazard, diagrams are developed for a single ‘top event’–one of the ways in which the hazard could be released. In principle, there can be multiple top events”
· “term ‘top event’ reflects the roots in Fault Tree Analysis, where the unwanted event is visually located at the top of the page”
· “Degradation factors are things that could cause a barrier to fail to do its intended job”
· “Safeguards are things that are intended to prevent the degradation factors from interfering with the functioning of the barrier”
· “A barrier must be effective, independent, and auditable’” and controls require at least these three criteria to be considered a full barrier”
· “Barriers can be either active or passive”
· “Active barriers commonly rely on a number of different ‘elements’ working together to deliver the functionality needed to detect, decide, and act”
· “Many, perhaps in a healthcare context the majority, of controls– and especially those that rely on people– cannot meet the quality criteria to be considered as full ‘barriers’”
· “Controls that do not meet the criteria, but nonetheless play an important role in protecting against incidents, are often referred to as ‘safeguards’”
· “…they are important– indeed, they frequently play a central role in safety management systems– but they cannot achieve the criteria required for full barriers”
· “A key output from BTA is clarity about what the real barriers are in any hazardous situation, and what are, in fact, safeguards”
SafetyInsights.org 