Medication administration safeguards
This bowtie maps the barriers around medication administration. On the left, it separates conditions that can lead to the top event: a medicine is given to the wrong patient. Barcode scanning, storage design and an uninterrupted workflow are preventative controls. On the right, it shows actions that limit harm once the medicine has reached the patient, including observation, rapid response and pharmacy review. The diagram is a structured conversation aid, not a substitute for local clinical policy or professional judgment. Tailor the threats and barriers to the medicine, care setting and electronic record used by the team. Record who owns each barrier and how the team checks that it is available when needed.
Open it in the AI editor with a prompt pre-filled — keep what works, change what doesn't.
Scenario
Medication safety review
Key decisions
- Top event: Define the loss of control before harm occurs.
- Threats: Separate packaging and workflow failures.
- Prevention: Put verification controls before administration.
- Recovery: Show care actions after the error reaches a patient.
When to reuse this
Use this during a medication-safety review or staff training discussion.
Frequently asked questions
What is the top event?
Why show recovery barriers?
Can this replace medication policy?
Tweak it with chat, export PNG/SVG, or fork it for your own use case.