“A medication administration bowtie: the hazard is medications used in patient care and the top event is a wrong medication reaching the patient. Show look-alike packaging, interruptions and incorrect patient identification as threats, with scanning, storage, protected rounds, records and identity checks as barriers. Show adverse reaction, ongoing treatment harm and delayed care with observation, rapid response, pharmacist, incident, prescriber and care-plan barriers.”
看懂背後的決策。
Define the loss of control before harm occurs.
Separate packaging and workflow failures.
Put verification controls before administration.
Show care actions after the error reaches a patient.
Use this during a medication-safety review or staff training discussion.
常見問題
What is the top event?
It is the moment a wrong medication reaches the patient, before a clinical outcome occurs.
Why show recovery barriers?
They make the actions that detect and reduce harm after the top event visible.
Can this replace medication policy?
No. Use it to discuss controls alongside the organisation's approved medication procedures.