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The Bowtie diagram: a simple tool for analysis and planning in anesthesia

The purpose is to show the advantages of a Bowtie diagram as a versatile tool for displaying and understanding the evolvement and management of critical incidents. RECENT FINDINGS: The Bowtie diagram has been used recently in anesthesia to depict critical incidents having been used in high-risk indu...

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Autores principales: Culwick, Martin D., Endlich, Yasmin, Prineas, Stavros N.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Lippincott Williams & Wilkins 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752234/
https://www.ncbi.nlm.nih.gov/pubmed/33044235
http://dx.doi.org/10.1097/ACO.0000000000000926
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author Culwick, Martin D.
Endlich, Yasmin
Prineas, Stavros N.
author_facet Culwick, Martin D.
Endlich, Yasmin
Prineas, Stavros N.
author_sort Culwick, Martin D.
collection PubMed
description The purpose is to show the advantages of a Bowtie diagram as a versatile tool for displaying and understanding the evolvement and management of critical incidents. RECENT FINDINGS: The Bowtie diagram has been used recently in anesthesia to depict critical incidents having been used in high-risk industries for several decades. This diagram displays the progression from latent factors to potential harm in five steps. SUMMARY: The Bowtie diagram combines the features of a fault tree and an event tree with the adverse event, known as the Top Event separating the two sections. The fault tree is similar in concept to a Swiss Cheese diagram and the event tree similar in concept to an emergency management algorithm. Preventive barriers and escalation measures are used to detect and trap abnormal states. If these fail, the event proceeds to a crisis, leading to the Top Event, a time for making decisions. A recovery state follows, which depicts an emergency state mandating immediate life or limb-saving management to recover from the crisis. Finally, in the aftermath state, a time for reflection and learning, ultimate outcomes are shown in the right-hand column. VIDEO ABSTRACT: The Bowtie Diagram. Designed and created by Yasmin Endlich, Martin D. Culwick and Stavros N. Prineas.
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spelling pubmed-77522342020-12-22 The Bowtie diagram: a simple tool for analysis and planning in anesthesia Culwick, Martin D. Endlich, Yasmin Prineas, Stavros N. Curr Opin Anaesthesiol TECHNOLOGY, EDUCATION AND SAFETY: Edited by Keith J. Ruskin The purpose is to show the advantages of a Bowtie diagram as a versatile tool for displaying and understanding the evolvement and management of critical incidents. RECENT FINDINGS: The Bowtie diagram has been used recently in anesthesia to depict critical incidents having been used in high-risk industries for several decades. This diagram displays the progression from latent factors to potential harm in five steps. SUMMARY: The Bowtie diagram combines the features of a fault tree and an event tree with the adverse event, known as the Top Event separating the two sections. The fault tree is similar in concept to a Swiss Cheese diagram and the event tree similar in concept to an emergency management algorithm. Preventive barriers and escalation measures are used to detect and trap abnormal states. If these fail, the event proceeds to a crisis, leading to the Top Event, a time for making decisions. A recovery state follows, which depicts an emergency state mandating immediate life or limb-saving management to recover from the crisis. Finally, in the aftermath state, a time for reflection and learning, ultimate outcomes are shown in the right-hand column. VIDEO ABSTRACT: The Bowtie Diagram. Designed and created by Yasmin Endlich, Martin D. Culwick and Stavros N. Prineas. Lippincott Williams & Wilkins 2020-12 2020-10-21 /pmc/articles/PMC7752234/ /pubmed/33044235 http://dx.doi.org/10.1097/ACO.0000000000000926 Text en Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. http://creativecommons.org/licenses/by-nc-nd/4.0 This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0
spellingShingle TECHNOLOGY, EDUCATION AND SAFETY: Edited by Keith J. Ruskin
Culwick, Martin D.
Endlich, Yasmin
Prineas, Stavros N.
The Bowtie diagram: a simple tool for analysis and planning in anesthesia
title The Bowtie diagram: a simple tool for analysis and planning in anesthesia
title_full The Bowtie diagram: a simple tool for analysis and planning in anesthesia
title_fullStr The Bowtie diagram: a simple tool for analysis and planning in anesthesia
title_full_unstemmed The Bowtie diagram: a simple tool for analysis and planning in anesthesia
title_short The Bowtie diagram: a simple tool for analysis and planning in anesthesia
title_sort bowtie diagram: a simple tool for analysis and planning in anesthesia
topic TECHNOLOGY, EDUCATION AND SAFETY: Edited by Keith J. Ruskin
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752234/
https://www.ncbi.nlm.nih.gov/pubmed/33044235
http://dx.doi.org/10.1097/ACO.0000000000000926
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