“A surgical site infection bowtie: the hazard is a surgical procedure with a wound and the top event is wound contamination. Show sterile technique, antibiotic timing and skin preparation as threats, with antisepsis, field checks, checklists and time-outs as barriers. Show infection, sepsis or readmission and prolonged recovery with assessment, treatment, escalation, infection control, multidisciplinary review and follow-up barriers.”
看懂背後的決策。
Keep the procedure context visible.
Use contamination rather than infection.
Place sterile and timing controls on threat paths.
Include surveillance and escalation after surgery.
Use for a perioperative safety discussion and adapt it to local protocols.
常見問題
Why is contamination the top event?
It marks the point at which preventative controls have failed, before infection develops.
What belongs on the left?
Threats and the barriers intended to stop them before contamination.
Who can use this diagram?
Perioperative, infection-control and quality-improvement teams can use it as a shared review aid.