The BowTies developed as part of this project are based on 10 relevant and recognizable patient safety topics. 1 - 4 example bowties have been developed for each patient safety theme.

 

The inspirational BowTies developed within this project are based on the 10 patient safety themes of a Dutch project called ‘VMS Veiligheidsprogramma’ (‘Safety Management System Safety Program’). This project aimed to reduce avoidable harm and fatalities in Dutch healthcare, by, amongst other things, publishing codes of practice for 10 patient safety themes.

These codes of practice were chosen as the basis for the BowTies because of the relevant issues, scientific basis and recognition of the patient safety themes. Click here to visit the Dutch healthcare safety agenda website for more information or to download the codes of practice (please note: these only available in Dutch and not in English).

1 - 4 example BowTies have been developed for each patient safety theme. Click here to view and download the healthcare example BowTies.

 

 

List of BowTies per patient safety theme

1. Surgical site infection
  1. Operating a patient - Surgical site infection
2. Sepsis
  1. Applying a central venous catheter (CVC) - Sepsis (infection of CVC)
3. Critically ill patients
  1. Treatment of critically ill patients - Inadequate or delayed treatment critically ill patient
4. Medication verification at admission and discharge
  1. Medication verification in handoff during hospital admission - Mismatch between medication used by patient and hospital records
  2. Medication verification in handoff during hospital discharge - Incorrect information about medicine use provided to stakeholders
  3. Medication verification in handoff during hospital discharge - Incorrect information about medicine use provided to stakeholders
  4. Administration of medicines - Patient receives wrong medication, wrong dose or wrong route of administration
5. Vulnerable elders
  1. Hospitalization of vulnerable elders (> 70 years) - Patient remains or becomes undernourished
  2. Hospitalization of vulnerable elders (> 70 years) - Patient develops avoidable loss of function
  3. Hospitalization of vulnerable elders (> 70 years) - Patient develops delirium
  4. Hospitalization of vulnerable elders (> 70 years) - Patient falls
6. Early recognition and treatment of pain
  1. Treatment of patient with pain - Delay in adequate treatment of pain
7. High risk medication parenterals
  1. Preparing parenterals (excluding cytostatic drugs) - Parenterals not prepared in accordance with the rules and / or prescription
  2. Administration of parenterals (excluding cytostatic drugs) - Parenterals not administered in accordance with the rules and / or prescription
8. Wrong operating procedure
  1. Performing surgical procedures - Applying incorrect procedure
9. Optimal care in Acute Coronary Syndromes
  1. Treatment of patients with acute coronary syndrome - Delay in adequate treatment

10. Preventing renal failure when using iodinated contrast agents

  1. Administering intravascular iodinated contrast media (excluding intensive care patients) - Renal impairment