Critical Incident for Bow-Tie Analysis

Assignment #4 (25 points): Final Project Critical Incident for Bow-Tie Analysis

In Week 7, the class 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. The instructor will provide an example. Each student will select a critical incident for approval by the instructor.

Topic:prevention of cross contamination and infection prevention  as it applies to the sterilization of surgical instruments. Discuss an incident that takes place in an hospital surgical room where cross contamination occurred from non-sterile instruments to patient.

Example of bow-tie analysis

Figure 7.1
Bow-Tie Example of a Critical Incident



  • Title Page
  • 1 page (double spaced) Page should clearly articulate what the critical incident is and provide background. 
  • 1 page Page should include the bow-tie analysis
  • Reference Page (2 references minimum)


Last Updated on February 10, 2019