Examined joint commissions framework for root cause analysis


Assignment: Project Critical Incident for Bow-Tie Analysis

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 graphic will appear as a bow-tie. The instructor will provide an example. Each student will select a critical incident for approval by the instructor.

The response should include a reference list. Double-space, using Times New Roman 12 pnt font, one-inch margins, and APA style of writing and citations.

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