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Barrier Management is a way to look at your normal operations from a risk perspective using the bowtie method.
and to manage critical “barriers” using existing data to see if you are “ALARP” (As Low As Reasonably Practicable”) and safe to operate.
This means:Being in control of your normal operations = working more efficient = working more safe = comply to rules and regulations = better quality = prevent incidents and accidents = minimize Non Production Time
The BowTie, named after its shape, contains eight elements: hazard, top event, threats, consequences, preventive barriers, recovery barriers, escalation factors and escalation factor barriers
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) Apply wris tband upon admiss ion to the ward Apply wris tband upon admission to the
ward
At admiss ion on the ward: Check the patient's identity by nurse together with patient through open questions
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) At admission on the ward: Check the patient's identity by nurse
together with patient through open questions
At admission on the ward: Check the
patient's identity by nurse together with
patient through open questions
At preoperative screening: Check the anethes ia tecnique by anesthes iologis t together with patient in accordance with the planned procedure
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong anethesia technique // (Br.) At preoperative screening: Check the anethesia
tecnique by anesthesiologist together with patient in accordance with the planned procedure
At preoperative screening: Check the
anethes ia tecnique by anesthes iologis t
together with patient in accordance with
the planned procedure
At preoperative screening: Check the diagnosis and procedure by anesthesiologist together with patient twith electronic medical record
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong procedure // (Br.) At preoperative screening: Check the diagnos is and procedure by
anesthesiologist together with patient twith elec tronic medical record
At preoperative screening: Check the
diagnosis and procedure by
anesthesiologist together with patient
twith electronic medical record
At preoperative screening: Check the operating s ite and s ide by anesthesiologist together with patient twith elec tronic medical record
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong site /side // (Br.) At preoperative screening: Check the operating s ite and side by
anesthesiologist together with patient twith elec tronic medical record
At preoperative screening: Check the
operating site and s ide by
anesthesiologist together with patient
twith electronic medical record
At preoperative screening: Check the patient's identity by anesthes iologis t together with patient through open questions
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) At preoperative screening: Check the patient's identity by
anesthesiologist together with patient through open questions
At preoperative screening: Check the
patient's identity by anesthesiologist
together with patient through open
questions
At surgery preparation room, check perioperative marking and completeness elecronic medical record by nurse and s taff member with awake patient
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong procedure // (Br.) At surgery preparation room, check perioperative mark ing and
completeness elecronic medical record by nurse and s taff member with awake patient
At surgery preparation room, check
perioperative marking and
completeness elecronic medical record
by nurse and staff member with awake
patient
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong site /side // (Br.) At surgery preparation room, check perioperative mark ing and
completeness elecronic medical record by nurse and s taff member with awake patient
At surgery preparation room, check
perioperative marking and
completeness elecronic medical record
by nurse and staff member with awake
patient
At surgery preparation room, check the patient's identity by anesthes iologis t and staff member with awake patient through open questions
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) At surgery preparation room, check the patient's identity by
anesthesiologist and s taff member with awake patient through open questions
At surgery preparation room, check the
patient's identity by anesthesiologist
and staff member with awake patient
through open questions
At surgery preparation room, check the patient's identity by nurse and staff member with awake patient through open questions
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) At surgery preparation room, check the patient's identity by nurse and
staff member with awake patient through open questions
At surgery preparation room, check the
patient's identity by nurse and staff
member with awake patient through
open questions
At the s tart of the surgey the surgeon, anaesthesiologist, operating assistant and nurse anesthetist and awake patient - check on the basis of the elec tronic medical
record / - whether it is the: right patient; right site and s ide; appropriate intervention; adequate supplies
(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong anethesia technique // (Br.) At the start of the surgey the surgeon, anaesthes iologis t,
operating assistant and nurse anesthetist and awake patient - check on the bas is of the elec tronic medical record / - whether it is the: right patient; right site and
Identification of weak spots, opportunities to improve and opportunities to make better use of resources / save time and money
For structure thinking
For risk based decision making
For communication & training
For monitoring the status of barriers
BowTie can be used in healthcare organizations such as hospitals to perform risk assessments. Bowtie has multiple advantages as a method for proactive risk analysis, for example the visual character or the diagram is ideal for risk communication.
How to get more information?http://www.patientsafetybowties.com/Events in your regionConferencesTraining (in house or open training)Workshops (in house or open training)In house pilot with your people and your dataBowTie Examples LibraryCGE Website (www.cgerisk.com)Blog (www.cgerisk.com/news/cge-blog)Newsletters (www.cgerisk.com/news/cge-newsletters)CGE YouTube channel (www.YouTube.com/CGErisk)Feel free to call us (+31 88 100 1350)Use our software for a trial periodWebinars1-1 online WebEx meetingsFeel free to invite us for a meeting at your officeWe are happy to introduce you to other industry leading clientsOur network of local consultancy partnersSend us an email ([email protected])
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 1
Case Study: Developing BowTies in a
Healthcare Setting
Recognition and Management of Acute
Hypercapnic Respiratory Failure -
Derby Teaching Hospital NHS Foundation Trust
Items to cover
• Clinical background
• Patient Harm
• Incident Investigation
• HF approach
• BowTie Modelling
• Identification of barriers
• Focus of resources
• Rollout
• Audit
2
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 2
Clinical Background to Project
• AHRF is a Medical Emergency
– High mortality
– Requires timely intervention
• AHRF results from an inability of the respiratory pump and lungs to provide sufficient alveolar ventilation to maintain a normal arterial PCO2.
• pH <7.35 and a PCO2 >6.5 kPa is defined as acute respiratory acidosis
3
Rationale for Project:Poor recognition & management of respiratory failure
• Median time from admission to NIV 4.1 hours
• 58% of those receiving NIV waited >3 hours
• 45% admitted had no oxygen prescription
• 41% Trusts had no oxygen training programme
4
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 3
Aims of project - Funded by HEE-EM
• Improve the recognition of AHRF as a medical emergency
• Improve the management of AHRF
• Ensure safe administration of oxygen and reduce harm events
• Understand why this happens and if by education and changing process management of these patients, outcomes will improve
• Engage departments, Doctors & Consultants with HF approaches to risk management
5
STEP 1
Patient Harm - Investigation
• 3 cases produced for HF review
• Case Timeline produced in
• Barrier Failure Analysis (BFA)
• At Derby, 120 further cases were analysed over a 2-3 month period.
• AHRF had a 48.9% inpatient mortality rate, rising to 62.5% including first 30 days as outpatient.
6
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 4
STEP 2
Engage Staff at all Levels in HF Approach
• 3 workshops
• Explain BowTie, Human Factors and Barrier
Management
• Collect views and ideas about Barriers
• Some of the content follows…
7
Human Factors Approach to Risk of Harm
• Complex Systems have numerous ‘failure’ points, where an unwanted outcome is produced - these may begin outside the focus of a local system or investigation of incidents
• Not all ‘failure’ leads to harm - many incidents are captured and recovered by the humans in a system
• So if we only protect against ‘harm’ - we may not be sufficiently protecting against ‘failure’ (and its distant effects)
• If we only investigate past incidents - we may not be able to fix the current problem or predict future issues.
• There are complex interactions within and between each part of a system that can vary its effectiveness.
HF addresses the whole system to focus on critical elements
leading to failure and harm
8
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 5
Human Factors Solution Development
1. What is the process designed to achieve?
2. Which systems influence or deliver that process?
3. How might each system (or step within it) fail?
4. How do we recover from the outcome of that failure? (recovery barrier)
5. How do we prevent that failure? (pro-active barrier)
6. Can we design better systems that work to achieve the process?
The system design must support the positive actions of the human factor, while protecting against negative ones.
9
Bow-Tie Method
10
Top Event
Hazard
Hazard Top Event
Hazard
Threat
Top Event
Hazard
Threat
Threat
Consequence
Top Event
Hazard
Threat
Threat
Consequence
Consequence
Top Event
Hazard
Preventive
Barrier
Preventive
Barrier
Threat
Preventive
Barrier
Preventive
Barrier
Threat
Consequence
Consequence
Preventive
Barrier
Top Event
Hazard
Preventive
Barrier
Preventive
Barrier
Threat
Preventive
Barrier
Preventive
Barrier
Threat
Recovery
Barrier
Recovery
Barrier
Consequence
Recovery
Barrier
Recovery
Barrier
Consequence
Recovery
Barrier
Escalation
Factor
Top Event
Hazard
Preventive
Barrier
Preventive
Barrier
Threat
Preventive
Barrier
Preventive
Barrier
Threat
Escalation Factor
Recovery
Barrier
Recovery
Barrier
Consequence
Recovery
Barrier
Recovery
Barrier
Consequence
Escalation Factor
Top Event
Hazard
Preventive Barrier
Preventive Barrier
Threat
Preventive
Barrier
Preventive
Barrier
Threat
EF Barrier
Escalation
Factor
Recovery Barrier
Recovery Barrier
Consequence
Recovery
Barrier
Recovery
Barrier
Consequence
EF Barrier
Escalation
Factor
EF Barrier
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 6
11
• Describes the desired state or activity
• Is part of normal business
• Has the potential to cause harm if control is lost
• Defines the context and scope of the BowTie diagram
E.g.: Driving a car, hydrocarbons in containment,
landing an aircraft
Hazard
• Is a deviation from the desired state or activity
• Happens before major damage has occurred
• It is still possible to recover
• Hazards can have multiple Top Events
E.g.: Losing control over the car, loss of (hydrocarbons)
containment, deviation from intended flight path
Top
Event
• Are credible causes for the Top Event
• Are not Barrier failures
• Should lead directly to the Top Event
• Should be able to lead independently to the Top Event
E.g.: Driving on a slippery road, pipeline corrosion, loss of
positional awareness
Threats
12
• Are the hazardous outcomes arising from the Top Event
• Describe the direct cause for loss or damage
• Describe how the damage occurs
E.g.: Car rollover, ignition of vapor cloud, mid-air collision
Consequences
• Are factors that reduce the effectiveness of a Barrier
• Should be used sparingly to highlight real issues
Tip: Focus on critical Barriers
Tip: Avoid repetition and duplication
E.g.: Forgetting to wear the seatbelt, no maintenance done,
person not trained
Escalation
Factors
• Prevent, control or mitigate undesired events or accidents
• Can be (a combination of) behaviour and hardware
• A Barrier System contains a detect, decide & act component
E.g.: Wearing a seatbelt, Blow-Out Preventer, Ground Proximity Warning
Barriers
• Escalation Factor Barrier - Reduces the effect of the Escalation Factor
• Recovery Barrier - Avoids or mitigates the Consequence
• Preventive Barrier - Eliminates the Threat or prevents the Top Event
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 7
Use of ‘Barrier Thinking’
• Barriers are ‘good’ - they stop you getting somewhere you DON’T want to be
– Anything that reduces the effectiveness of a Barrier needs to be addressed
13
Use of ‘Barrier Thinking’
• Obstacles are ‘bad’ - they stop you getting
somewhere you DO want to be
14
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 8
Barrier or Obstacle?May depend who you ask……
15
Barrier Attributes
• Should be:
– Effective
– Reliable
– Robust
– Auditable
• What types of Barrier?
– Behavioural
– Procedural
– Socio-Technical
– Hardware
o Passive, Active or Continuous
16
RELIABILITY
Poor
Good Poor
Good
FLEXIBILITY
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 9
Understanding Barriers in Complex Systems
• Effective Barriers to system failure can be people, actions,
equipment, procedures, infrastructure etc.
• Each will perform at varying levels of effectiveness
• Effectiveness can be degraded (risk of failure escalated) by
a wide range of factors
• Each Escalation factor needs 1 or more barriers in place
• Each of those may be degraded in turn.……
This complexity is best managed & displayed using BowTie
17
STEP 3
Explore the Bow-Tie model for AHRF project
• Link to Bow-Tie XP
18
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 10
STEP 4
Development Areas from AHRF Bow-Tie
1. Awareness of AHRF clinical presentation, treatment and referral
2. Maintenance of Critical Information at handovers– Conflicts between competing systems (iCM, Patient
Track, written notes)
3. Accuracy and frequency of information (from Arterial Blood Gases)
4. Escalation to Senior Decision Maker - correct information and method
19
Exploded Diagrams - Prevention Barriers
20
Focus project
resources here
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 11
Exploded Diagrams - Escalation Barriers
21
Exploded Diagrams - Recovery Barriers
22
Focus project
resources here
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 12
Exploded Diagrams - Escalation Barriers
23
STEP 5
Interventions
• Training
– Simulation for AHRF recognition & NIV
– Taking of Arterial Blood Gases / use of Capillary
Blood Gases
– Ward based awareness of AHRF - (Superheroes)
– ACPs, F1 and F2 in awareness of system updates,
checklist use and case management steps
24
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 13
Interventions
• Electronic Information
– iCM auto-update of ABG results
– Alert developed for respiratory acidosis
– Flag links to AHRF immediate case management
checklist (electronic and hard copy available)
– Icon introduced to electronic whiteboard
25
Interventions
• Checklist for Immediate Case Management– Recording of action times to improve tracking
– Prompts for required actions such as: collecting ABG, prescription of correct target oxygen saturation, and use of wristband
– Assistance with decision making based on ABG results
– Guide to improve quality of referral to senior decision maker, including information to hand during call and clear script statements to assist communication under pressure
26
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 14
Next Steps
• Collect data for another 120 cases over 2-3 month period
• Determine impact from introduced and strengthened barriers
• Refine barriers based on feedback
• Audit barriers following identification of Leading Indicators - (F1 & F2 rotations, winter, iCM changes, Pharmacy space restrictions, etc)
• [See Audit Filter ‘on’ for AHRF model]
27
A year in the life of Bow-tie XP
Bryan Healy Head of Risk BWCH March 2017
Our story
1. The Background
2. The Paper BT
3. First ever deployment
4. My favourite story
5. A work in progress
6. Some interesting observations
7. Why I’m a fan
8. What’s next?
The background
• Saw these guys at a conference – Nov 2013?
• Intrigued but moved on.
• Then came across a problem.
• We wanted to refurb a ward
• But were terrified by the risk of dust
• But had to improve the patient experience, had made
commitments to patients and raised charitable funds.
• Our CMO said, “Could you do us a risk assessment?”
• So I did a bow-tie on paper…lots of paper
The paper BT
What ended with was
a map and that was
priceless.
The paper BT
• The bow-tie provided a model that everyone could understand
• Everything was on the same page
• Everything could be challenged
• Everyone was able to realise challenges in maintaining controls
• We had no appetite for the risk and the building work was cancelled.
Lesson 1: The bow-tie maps a system, giving a
holistic view of what’s going on, what interacts and
what’s important.
Sometime in 2015
• MY CMO sent me an e-mail from a friend of
his.
• That friend loved bow-ties, worked with CGE
and was doing a workshop in Birmingham.
• I went along
• I was impressed.
• I told my boss we needed this.
• We got it and then what?
Lesson 2: Making the case with a bow-tie
Lesson 2
The holistic view of this situation:
• Gave us the ability to articulate a complex story.
• Gave structure to the conversation.
• Had strong visual impact
Plus
• We’d developed a framework for potential future evaluation exercises
• And the software earned its’ stripes
• …so then what?
My favourite story
It took us 45
minutes
It is purely
qualitative
Each threat
represents a
different system
level
Lesson 3:
“We’ve spent weeks looking at this…I know what to do
now”
You don’t have to be an expert every time
You don’t have to complicate things
A work in progress
• SIRI.
• 10 x overdose (no
harm)
• Recommendation:
risk assess 10 x
OD.
• So we mapped
the system of
threats and
controls.
Zooming in
• And suggested
some escalation
factors. • Then began working
through ap.600 incidents
collected over a 6 month
period
Analysing Incidents
Recovering controls
13 Recognition: through checking processes for subsequent
administrations
14 Other Investigations / clinical monitoring
15 Blood test
16 Culture of secrecy
17 Monitoring alarms
18 Treatment
19 parent call for help
20 Clinical resuscitation
Preventing Controls
1 Nurse (administrator) double checking process
2 Pharmacist check
3 Prescription reviews by clinicians
4 Parental involvement in checking
5 Prescription training
6 Prescribing areas
7 Drug prep area
8 Use of smart pumps with drug libraries, hard and soft
limits
9 Drug labelling
10 Personal diligence
11 Double check of pump programming
12 Parental/ patient involvement in checking
Our most frequently failing controls
Preventative controls
Prescription
calculation
error
Unclear
Prescription
Transcription
error Wrong
preparation
Rate
Programme
error
Personal diligence 69% 67% 50% 21% 11%
Administrator double checking process 5% 0% 25% 71% 37%
Pharmacist check 12% 17% 0% 2% 0%
Prescription reviews by clinicians 10% 0% 25% 0% 0%
Double check of pump programming 0% 0% 0% 0% 37%
Recovering controls
Prescription
calculation error
Unclear
Prescription
Transcription
error Wrong
preparation
Rate
Programme error
Doses>0.1ml
Administrator double
checking process 35% 50% 25% 24% 26% 0%
Pharmacist check 16% 0% 25% 5% 5% 0%
Prescription reviews by
clinicians 4% 17% 0% 0% 5% 0%
Parental involvement 6% 17% 13% 3% 5% 0%
Checking for subsequent
administrations 16% 0% 13% 10% 32% 100%
Other Investigations /
clinical monitoring 2% 0% 0% 13% 16% 0%
A Lesson About Content
4. A useful aspect of BT is the ability to characterise barrier
types
All our controls are behavioural
This is the technical one
Another Lesson About Content
5. There is a hierarchy
of outcomes which
people always reach
for
Why I’m a fan
• When we couldn’t refurbish the ward,
something else happened
Oncology build BT
The Problem
• The new building is on
the other side of site.
• Will this delay our
assessment of acutely
ill patients?
• How would that come
about?
Oncology build BT
The Problem
• The new building is on
the other side of site.
• Will this delay our
assessment of acutely
ill patients?
• And what would that
mean for our patients?
Oncology build BT The Process
1. We met with the team and asked them their
worries
2. We talked through what would be needed to
mitigate the risk.
3. Together we mapped the worries
Oncology build BT The Process
4. We met again to discuss the BT
5. We talked through the controls and discussed how
far they are currently implemented
6. Then we could focus on how we might mitigate the
residual risk residual risk
Lesson 6
The BT is a powerful knowledge-brokering tool
KBT’s have 3 characteristics
• They are concrete.
• They represent relationships
between stakeholders.
• Anyone can change them.
• This has a form that the clinical
team came together around.
• It described the connections
which were important to them
• We developed it in a group
session – users could print it out
and stick it on the wall- scribble
on their ideas
A quick one
Quality Finance
Productivity
A quick one
Problem
Work Harder Unsustainable
Defect Correction
Sunk Costs
Tackle the problem
The smart answer
A quick one
Work Harder
Defect Correction
Tackle the problem
Summary
How we’ve used them Where we’ve used them
Problem solving Service
capacity
Investigations Never
Events
Analysis Medication
Errors
Needle-
sticks V&A
Info
Security
Infection
Control
Equipment Workflow
Final Thoughts A lesson about process
7. We’ve not integrated Bow-ties with our
business intelligence yet…and I don’t know
how to.
But the clue lies somewhere in answering a few questions:
• Is BT central to our risk strategy?
• What place bow-ties in an NHS addicted to incidents?
Positive reporting culture [39.85 per 1000 bed days] – April to Sep 15
0
10
20
30
40
50
60
70
0 50000 100000 150000 200000 250000 300000
Rate
per
1,0
00 B
ed
Days p
er
Year
Bed Days
Incidents per 1000 Bed Days for Acute Trusts (non-specialist)
Data
Average
2SD limits
3SD limits
Source: Incidents which occurred between 1st April 2015 and 30th September 2015 (reported to the National Reporting and Learning System (NRLS) by the 30th
November 2015)
Hu-Tech Human Factors
Hu-Tech Human Factors 18/04/2017
CGE Risk Management 4
Days between Never Events at NUH
Days between Never Events (by date of incident, 2011 to Sept 2016)
Hu-Tech Human Factors
Analysis of 9 Never Events
September 2015 to August 2016 (12 rolling months) - 9 Never Events reported: