HMGT 320 7980 Management in Health Care Organizations: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
•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)
•Written document should conform to American Psychological
Association (APA) 6th Edition
Please Read Carefully:
1. Topic Selection: Select a topic for the bow-tie analysis. You
may select any topic and a list of examples topics have been
i. Child abduction from a hospital unit or infant discharge to
the wrong person
- Discussion: One page minimum, clearly articulating the critical
incident, or sentinel event, with a background on the topic that
will be discussed.
o Important information to include in the 1-page discussion:
Information on the situation for conducting a root cause
analysis (RCA) using the quality improvement tool of the
bow-tie analysis, which could describe the parties involved
in the incident (healthcare setting’s leadership, clinical team,
patients, or other parties); what was being examined (topic
selection information); why was the information being
examined; what was the issue being examined based on the
topic selection information; potential ways the bow-tie
analysis can support in resolving the issue; and an overview
of how the bow-tie analysis was conducted.
o Clear & Concise Information: The discussion on the event
must allow for a clear understanding regarding the situation
that was applied for the bow-tie analysis.
o Approaches for the Discussion Aspect of the Task: Students
may elect to present this information in a variety of ways.
Examples: Standard paragraph form for the one-page
minimum discussion; an introduction with a table of the
items listed above with a closing paragraph; information
presented in paragraph form followed by bulleted items
listed above; or provide any other applicable discussion
approach that demonstrates sound knowledge for all the
required aspects for this task.
- Illustration: Conduct the bow-tie analysis: 1-page
illustration of a completed bow-tie analysis.
o The bow-tie analysis should be reflective of the information
provided within the discussion aspect of this task.
o Bow-Tie Examples: Refer to reading materials for reference
on how to conduct a bow-tie analysis or obtain examples
from the UMUC library.
o Student’s Original Work: Copyrighted pictures, pictures
from the internet, scanned images or other images are
NOT allowed. The bow-tie analysis must be the student’s
original work regarding the task that is being performed.
Students may elect to complete the analysis in a
separate document or complete the analysis on the same
submission as the discussion aspect. Students that have
taken this course previously have elected to use a secondary
document such as Excel, Publisher, or PowerPoint to show
their illustration. The illustration must be legible for full
evaluation, meaning the illustration needs to clear enough to
be read and examined for the bow-tie analysis.
- Minimum 2 External Sources: Ensure at least two scholarly
resources are provided and supported throughout the paper for
supporting evidence. Students may elect to use the references
provided within the final week or select other scholarly sources
for the discussion.