Running Head: LAW 1
Bow-Tie Analysis is one of many effective tools for communicating risk assessment. BTA not only identify the actions, inaction and gaps leading up to the error or violation, the BTA also diagrams specific factors in the resolution of the violation.
1. State a specific legal or ethical violation.
2. Examine the violation by applying the BTA or provide another specific example of an effective tool that HCO’s use for risk assessment. Provide a reference for the method you choose.
3. Describe your method and contrast it with the BTA.
4. As HCO managers, which assessment tool would you implement to prevent this violation and why?
5. Provide specifics on how the method would help your organization. Is there any setting that the BTA or risk assessment tool would not work?
Peers are expected to demonstrate critical thinking in their questions related to the classmates’ descriptions. SeeDiscussion Expectations and Gradingfor rules on discussions.
Assigned reading materials:
· Abdi, Z., Ravaghi, H., Abbasi, M., Delgoshaei, B., & Esfandiari, S. (2016). Application of bow-tie methodology to improve patient safety.International Journal of Health Care Quality Assurance, 29(4), 425-440. doi: Retrieved from
· Kadivar, M., Manookian, A., Asghari, F., Niknafs, N., Okazi, A., & Zarvani, A. (2017). Ethical and legal aspects of patient’s safety: a clinical case report.Journal of medical ethics and history of medicine,10, 15.Retrieved
Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCSEng(Hon), FRCSEd(Hon) February 1, 2020
Revisiting To Err Is Human 20 years later
The Institute of Medicine (IOM, now known as
the National Academy of Medicine) 20 years
ago published the landmark report, To Err Is
Human: Building a Safer Health System. This
report increased awareness of medical errors
in the U.S. and also called for health care
system changes that would lead to
improvements in patient safety and quality of
The report cited a study that estimated at least
44,000 patients die annually in the U.S. as a
result of medical errors, with an additional
study suggesting it could be as high as
98,000.The report also stated that deaths
attributed to medical errors exceeded “the
number attributable to the eighth-leading cause of death,” which at the time was suicide.
More importantly, the report highlighted the fact that most medical errors were the result of
failures of the system rather than specifically attributable to individuals.
Still work to be done
Two decades later, Mark R. Chassin, MD, FACP, MPP, MPH, president and chief executive
officer of The Joint Commission—a member of the IOM Committee on Quality of Health Care
in America that wrote the To Err Is Human report—believes that although that report and
others have led to improvements in the health care system, the rates of familiar quality
issues remain too high.
For surgeons, quality issues that still demand attention include wrong-site surgery and the
continued incidence of unintended retained foreign objects (URFOs). URFOs were the top
sentinel event reported to The Joint Commission in 2017 (124 reported) and again in 2018
(121 reported). A total of 104 incidents of wrong-patient, wrong-site, wrong-procedure events
were reported in 2017, with another 98 reported in 2018.
Dr. Chassin touched on the To Err Is Human report and more in a Modern Healthcare
editorial, “One-size-fits-all approach to patient safety improvement won’t get us to the
ultimate goal—zero harm.” Dr. Chassin laid out three changes health care leadership can
make to ensure patients receive higher quality care. They are as follows:

Revisiting To Err Is Human 20 years later

Commit to a goal of zero harm
Drastically overhaul the institutional culture
Understand that safety processes often fail at rates of 50 percent or more
In the Modern Healthcare commentary, Dr. Chassin also wrote that “the method we have
employed is the ‘one-size-fits-all’ best practice.”But that approach often leads to modest or
inconsistent improvements that are difficult to sustain over time.
“We cannot continue to use the same methods and expect different results,” Dr. Chassin
wrote. “Evidence is accumulating that process improvement methods long used successfully
in industry—Lean, Six Sigma and change management, taken together—are far more
effective than the ‘one-size-fits-all’ best-practice approach.”
Dr. Chassin also spoke with Nancy Foster, American Hospital Association vice-president for
quality and patient safety, for the Advancing Health podcast. In the episode, Dr. Chassin
described the impact of the To Err Is Human report on health care safety.
Now what?
So where do we go from here? In a recent High Reliability Healthcare blog post, Dr. Chassin
reflected on the future impact of To Err Is Human and how health care can continue to
improve. “We’ve made some significant progress, but the next major gains will arise only
from the efforts of health care leadership and organizations, not government, business,
market forces, nor patient advocacy groups,” Dr. Chassin wrote.
He also asked that after 20 years, “Who is satisfied with the current state?” He noted, “If
we’re not satisfied, we need to change the way we have been going about improvement.”
The report marked a pivotal moment in the health care industry, policymaking, and society’s
expectations about how health care is provided.
My personal take on the IOM report is positive. I believe that before the report was
published, health care leaders were primarily focused on innovation. The report marked a
pivotal moment in the health care industry, policymaking, and society’s expectations about
how health care is provided. Starting in early 2000 (the report was released in November
1999), attention rapidly shifted from a focus on innovation as a way to advance health care to
a focus on safety. That movement toward safety has grown ever since, and that, I believe,
has provided enormous benefits to our patients.
Am I satisfied with the rate of harm surgical patients continue to experience? Of course not.
However, safety is not a static goal line but rather a moving target. New processes, new
devices, new ways of providing treatment—yes, innovation—continues full throttle, and while
these advances have benefited society in a significant way, they also have created
vulnerability and risks that were not present before. Managing those risks, creating a culture
of safety, and continuing to focus on ways to identify and eliminate threats before they
become errors is, in my view, the greatest legacy of this report and a moral imperative for
every surgeon.
The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do
not necessarily reflect those of The Joint Commission or the American College of Surgeons.
1. Institute of Medicine (U.S.) Committee on Quality of Health Care in America, Kohn LT,
Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System.
Washington (DC): National Academies Press (US); 2000. Executive Summary.
Available at: Accessed December 30, 2019.
2. National Vital Statistics Reports. Centers for Disease Control and Prevention (National
Center for Health Statistics). Deaths: Final data for 1997. June 30, 1999. Available at: Accessed December 30, 2019.
3. National Vital Statistics Reports. Centers for Disease Control and Prevention (National
Center for Health Statistics). Births and deaths: Preliminary data for 1998. October 5,
1999. Available at: Accessed
December 30, 2019.
4. Chassin M. One-size-fits-all approach to patient safety improvement won’t get us to the
ultimate goal—zero harm. Mod Healthcare. Available at:
improvement-wont-get-us-ultimate-goal. Accessed December 30, 2019.
5. American Hospital Association patient safety leader reflects on ‘To Err is Human’
report. Advancing Health. Available at:
11-13-patient-safety-leader-reflects-err-human-report. Accessed December 30, 2019.
6. Chassin M. To Err is Human: The next 20 years. The Joint Commission High Reliability
Healthcare blog. Available at:
Accessed December 30, 2019.

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