In my class we examined the Joint Commission’s framework for root cause analysis of sentinel Incidents in health care organizations. For purposes of this project, a critical incident is a key occurrence, but it is not a sentinel event. A bow-tie analysis places the critical incident at the center of the framework and identifies in graphic format the root cause leading up to the incident on the left side of the critical incident. On the right side of the incident, key preventive measures are graphically represented. In one image, you will capture the incident (at the center), the causes for failure in quality, and (on the right) preventive measures a manager can put in place to stop this failure from happening in the future. The final graphic will appear as a bow-tie. Please see the Attached sample bow tie !.
Please inbox/message me the critical incident you intend to use so I can get approval by the instructor before you start. I will add an extra day to give you time to send it to me.
This project must include a cover page, a one-page explanation, a one-page graphic image (bow-tie analysis), and references.