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Improving Patient Safety in the ICU by Prospective Identification of Missing Safety Barriers Using the Bow-Tie Prospective Risk Analysis Model

Kerckhoffs, Monika C. MD*†; van der Sluijs, Alexander F. MD*; Binnekade, Jan M. PhD*; Dongelmans, Dave A. MD, PhD*

doi: 10.1097/PTS.0b013e318288a476
Original Articles

Objectives To improve patient safety, potential critical events should be analyzed for the existence of preventive barriers. The aim of this study was to prospectively identify existing and missing barriers using the Bow-Tie model. We expected that the analysis of these barriers would lead to feasible recommendations to improve safety in daily patient care.

Methods Multidisciplinary teams of doctors and nurses on a 28 bed ICU conducted the study. The Bow-Tie analysis was performed on intrahospital transportation, unplanned extubation, and communication, which led to 9 critical events. For each event, potential threats and consequences were defined and placed in a Bow-Tie diagram. Then, barriers were determined, ways to prevent the threat or limit the consequences. The barriers were defined as existing or missing and analyzed for feasibility.

Results Intrahospital transportation: this hazard led to 7 critical events, the Bow-Tie analysis to 52 missing but implementable barriers and 8 practical recommendations. For example, a pretransportation checklist.

Unplanned extubation: this Bow-Tie analysis revealed 15 implementable missing barriers (of a total of 32) and led to 22 recommendations. One of them was optimizing treatment of delirium.

Communication: this analysis showed 21 barriers, of which, 12 were missing but feasible to implement. These barriers led to7 recommendations such as the need to cosign after the handover of a patient.

Conclusions Prospective risk analysis using the Bow-Tie model proved usable to identify existing and missing barriers for potential critical events. Many missing barriers seemed feasible to implement and led to practical recommendations and improvements in patient safety.

From the *Department of Intensive Care Medicine, Academic Medical Centre, Amsterdam; †Currently working in the Department of Intensive Care Medicine, University Medical Center, Utrecht, The Netherlands.

Correspondence: Monika Kerckhoffs, MD, Department of Intensive Care, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (e-mail:

The authors disclose no conflict of interest.

© 2013 by Lippincott Williams & Wilkins