1. Topic Selection: Select a topic for the bow-tie analysis. You may select any topic and a list of examples topics have been provided below

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
•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)
•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
provided below. 
a. Topic:

      i. Child abduction from a hospital unit or infant discharge to
the wrong person

  1. 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.
  2. 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.

  1. 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.
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