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A Comparison of the Bow-Tie and STAMP Approaches to Reduce the Risk of Surgical Instrument Retention

Accepted version
Peer-reviewed

Type

Article

Change log

Authors

Chatzimichailidou, MM 
Ward, JR 
Horberry, T 
Clarkson, PJ 

Abstract

Although relatively rare, surgical instrument retention inside a patient following Central Venous Catheterisation still presents a significant risk. The research presented here compared two approaches to help reduce retention risk: Bow-Tie Analysis and Systems- Theoretic Accident Model and Processes. Each method was undertaken separately and then the results of the two approaches were compared and combined. Both approaches produced beneficial results that added to existing domain knowledge, and a combination of the two methods was found to be beneficial. For example, the bow-tie analysis gave an overview of which activities keep controls working and who is responsible for each control, and the Systems-Theoretic Accident Model and Processes revealed the safety constraints that were not enforced by the supervisor of the controlled process. Such two-way feedback between both methods is potentially helpful for improving patient safety. Further methodology ideas to minimise surgical instrument retention risks are also described.

Description

Keywords

bow-tie, CVC process, guidewire retention, STAMP, STPA

Journal Title

Risk Analysis

Conference Name

Journal ISSN

0272-4332
1539-6924

Volume Title

Publisher

Wiley
Sponsorship
National Institute for Health Research (NIHR) (via Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) (unknown)
This research was part-funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East of England (CLAHRC EoE) at Cambridge and Peterborough NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health. Additional funding was provided by Cambridge University Hospitals NHS Foundation Trust. Cambridge University Hospitals NHS Foundation Trust