Bow Tie Analysis: Critical Incident Patient Safety – Medical Ethics Example

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"Bow Tie Analysis: Critical Incident Patient Safety"  is a good example of a paper on medical ethics. Errors and mistakes by medical staff during patient treatment can cause serious results such as loss of life or incapacitation. It is for this reason that patient safety has been so popular lately. Patient safety seeks to identify, investigate, and prevent incidents of errors in medical care. This paper will give an example of an incident where a patient’ s safety was compromised and the investigations of the root cause carried out. This information will then be presented in a bow tie analysis. The incident here involved a patient who had been infused with the wrong blood unit.

The patient had been involved in a serious accident that had resulted in several fatalities. The patient was rushed to a nearby hospital by a group of rescuers. Upon receipt of the injured man by the hospital’ s medical staff, an examination was hastily carried out by the resident doctor. The doctor realized that the bleeding had exceeded Class II hemorrhage and that he needed an immediate blood transfusion. His blood sample was determined and this information was sent to staff at the blood bank.

Staff in the blood bank realized that there was no blood available for the patient’ s blood group and they immediately called for a donor. Two donors were found who donated a total of four pints of blood. Blood was taken from the donation center to the transfusion center. Unfortunately, there was a mix up as the blood kit used to infuse the patient was not the one containing his blood type. Immediately after the infusion, the patient died and investigations as to the cause of his death began immediately.

It was soon realized that the cause was a human error. A root cause analysis was carried out and at first; questions were raised as to whether the required steps were followed. It was determined that as a result of the hurry involved some of the steps were skipped. It was determined that the cause of death was human errors as the medical staff was fully qualified, competent, and had adequate experience  (Joint Commission, 2013).


Joint Commission. (2013, March 22). Framework for Conducting a Root Cause Analysis and Action Plan. Retrieved February 27, 2015, from Joint Commission Website:

World Helath Organization. (2008). World Alliance for Patient Safety Progress Report 2006-2007. Washington D.C.: World Health Organization.

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