bow tie analysis

umuc_bow_tie_analysis-1.xlsx

Sheet1

wrong drug put in Pyxis by pharm tech			pharmacy staff to double check Pyxis refills
med supplier switches manufacturer of drug			pharmacy staff to alert nursing of a medication manufacturer change
double check of Pyxis refill not done		near miss medication error	nurse to double check and question medications that "look different"
nurse did not check med twice			clinical pharmacist who works on the floor to be consulted
	Inpatient, Ms. Jones has a blue pill given to her instead of the usual yellow one for her CHF. Confused, she calls
	the nurse and notes the color change. This causes the nurse to call the pharmacy and ask about the different pill color
	and if this is correct for Ms. Jones. It turns out that it is not correct. The correct drug is then found and administered and
	an incident report is completed.
	Causes of incident paragraph
	Preventive measures paragraph
References: (articles on medication safety, medication errors, etc)