“An inpatient fall bowtie: the hazard is a patient with mobility needs and the top event is a fall while mobilising. Show toileting, sedating medicine and clutter as threats, with call bells, toileting, medication, mobility and environmental barriers. Show injury, loss of confidence and longer stay with assessment, imaging, physiotherapy, care-plan, review and discharge barriers.”
看懂背後的決策。
State the fall, not its injury.
Separate clinical and environmental contributors.
Name practical bedside controls.
Include assessment and rehabilitation.
Use in a ward safety huddle or fall-prevention review.
常見問題
What is the top event in this example?
The patient falling while mobilising is the top event; injury is a consequence.
Can environmental factors be added?
Yes. Lighting, clutter and unsuitable footwear can be added as threats with their controls.
Is this a patient assessment tool?
No. It is a team-level barrier map that complements individual assessment.