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Aim: This study aimed to assess the risk management of drug safety in an operating theater setting within a hospital-based treatment facility. Materials and methods: This is a case study detailing a single patient. The bow-tie model was modified for analyzing medication errors in anesthesiology practice and implemented in the operating room of the university hospital. The diagram was created using well-established methods. The data was gathered using an online portal (www.rsps.bg) designed to evaluate hospital safety culture and report incidents. Results: The Striped Bow Tie® methodology-built model illustrated the primary reasons for the medication error. The risk score was estimated to be 12 based on the specified parameters. The severity is rated on a 4-point scale ranging from catastrophic (4), critical (3), marginal (2), to negligible (1). The likelihood is assessed on a 5-point scale from frequent (5), probable (4), occasional (3), moderate (2), to unlikely (1). Preventive methods were suggested to minimize the risk, avert the incident, and manage the process. Conclusion: The bow-tie approach is suitable and simple to apply in hospital anesthesia practice and serves as an essential instrument for analyzing medication safety risks. The analysis demonstrated systemic errors that led to the incident, including unrealized potential for continuing medical education and transforming the hospital into a place where clinicians can constantly learn by reporting adverse events and medical errors. |
