Medication error — high-risk infusion
Wrong dose of a high-risk IV medicine: look-alike drugs, pump programming and patient identity, recovered by monitoring and rapid response.
4 threats 14 barriers 3 consequences safety-critical barriers marked
Use this template free. Copy “Medication error — high-risk infusion” into your own workspace and adapt every barrier — no credit card.
Start free with this template →Threats & preventive barriers
Each threat is a credible pathway to the top event; its barriers interrupt that pathway before control is lost.
Look-alike / sound-alike drug mix-up
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Barcode medication verification ★ critical
Active hardware · 90% effective · Owner: Pharmacy IT Lead
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Tall-man lettering & segregated storage
Passive (hardware) · 70% effective · Owner: Pharmacy Lead
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Clinical pharmacist review
Socio-technical · 85% effective · Owner: Chief Pharmacist
Infusion pump misprogramming
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Smart-pump dose-limit library ★ critical
Active hardware · 92% effective · Owner: Biomedical Engineering
Drug library not kept up to date
📅 Drug library update · quarterly keep-alive task
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Independent double-check
Behavioural (human) · 80% effective · Owner: Ward Nurse Manager
Workload pressure skips the check
Prescribing error
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CPOE with clinical decision support
Active hardware · 85% effective · Owner: Clinical IT Lead
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Weight-based dosing protocol
Socio-technical · 80% effective · Owner: Clinical Lead
Wrong patient
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Two-identifier check at the bedside ★ critical
Behavioural (human) · 80% effective · Owner: Bedside Nurse
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Wristband barcode scan
Active hardware · 85% effective · Owner: Nursing Director
Consequences & recovery barriers
Once the top event happens, recovery barriers limit each consequence.
Patient harm
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Continuous patient monitoring
Active hardware · 80% effective · Owner: Nursing Director
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Rapid response team & antidote protocol ★ critical
Socio-technical · 85% effective · Owner: Critical Care Lead
📅 Rapid response simulation · semiannual keep-alive task
Reportable adverse event
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Incident reporting & review
Socio-technical · 80% effective · Owner: Patient Safety Lead
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Root-cause analysis with actions
Socio-technical · 75% effective · Owner: Quality Director
Loss of trust & litigation
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Open disclosure & duty of candour
Behavioural (human) · 70% effective · Owner: Medical Director
Copying this template gives you a fully editable bowtie: barrier owners arrive as role suggestions, escalation factors sit on their barriers, and keep-alive activities are scheduled from the moment you copy. New to the notation? Read what the bowtie method is or browse the practical guides.
Use this template free. Copy “Medication error — high-risk infusion” into your own workspace and adapt every barrier — no credit card.
Start free with this template →