1 TFT 1000 2F 9 30 9 35 ( ) 9 35 9 50 14 ( ) 10 00 10 50 ( ) 11 00 12 00 ( ) 13 10 14 10 1 ( ) 14 20 16 10 1 BOK 1-1 1-2 1 11 23 1 43
1-3 1-4 16 20 17 20 1 NTT 1-1 1-2 2 TFT 500 2F 1 2 10 00 12 00 2 2-1 2-2 2-3 PMS 2-4 44 1 11 23 1 2
12 00 12 50 1 WHO ( ) 14 20 16 20 1 1-1 WHO 1-2 1-3 WHO 16 30 18 00 3 3-1 3-2 3-3 3-4 1 11 23 2 45
3-5 3 TFT 300 2F 2 3 10 00 12 00 4 ) 4-1 4-2 4-3 4-4 4-5 12 00 12 50 2 MSD ( ) 46 1 11 23 2 3
14 20 16 20 5 5-1 1,2 1,3 1 2 3 5-2 1 1 1 1 1 2 1 2 5-3 5-4 5-5 1 2 3 1 2 3 5-6 1 2 3 1 2 3 16 30 18 00 6 6-1 IHE-PCD 6-2 6-3 1 11 23 3 47
4 TFT 9F 908 10 00 11 30 7 7-1 7-2 7-3 VRE 7-4 7-5 12 00 12 50 3 minimum requirement ( ) 14 20 16 20 8 8-1 IVR II 48 1 11 23 4
8-2 1 2 1 2 8-3 8-4 8-5 IVR NTT 8-6 IA 16 30 17 30 2 N 2-1 2-2 2-3 MT 17 40 18 25 1 1-1 1-2 Patient Safety 1-3 1 11 23 4 49
1-4 HIV/ 1-5 10 5 TFT 9F 909 4 5 10 00 10 54 2 1 2-1 SHELL 2-2 1 1 2 2 2 1 3 1 2 3 2-3 2 1 2 2 2 1 3 1 2 3 2-4 17 3 22 2-5 1 1 1 1 2 1 2 2-6 11 00 11 45 3 CVC 3-1 1 1 1 1 1 1 1 1 1 2 1 2 3-2 50 1 11 23 4 5
3-3 CVC 2 1,2 1 3 2 2 1 2 1 2 3 3-4 3-5 2 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 12 00 12 50 4 PICC ( ) 14 20 15 14 4 2 4-1 4-2 4-3 4 4-4 4-5 1,2 2 3 1 1 1 2 3 4-6 3b 3 1 11 23 5 51
15 20 16 23 5 3 5-1 5-2 1 1 1 1 1 1 2 2 2 1 2 5-3 1 2 2 1 2 5-4 5-5 1 1 1 1 2 1 2 5-6 1 2 2 2 1 2 5-7 16 30 17 24 6 4 6-1 6-2 1 2 2 2 2 1 3 1 1 2 3 6-3 1 1 1 2 2 1 2 6-4 1 1 2 1 1 2 52 1 11 23 5
6-5 6-6 - 1 1 2 3 1 2 3 17 30 18 24 7 1 7-1 1 2 1 2 7-2 7-3 1 1 1 1 1,2 1 2 7-4 1 2 2 3 3 4 1 / 2 3 4 7-5 SST 1 2 2 2 2 2 3 4 5 5 1 2 3 4 5 7-6 1 2 3 4 2 1 2 3 4 1 11 23 5 53
6 TFT 9F 9-A 10 00 10 45 8 8-1 8-2 MRI 1,2 1 2 8-3 8-4 8-5 1,5 2,5 3,5 4,5 5 5 5,6 1 1 2 3 4 5 6 11 00 11 54 9 9-1 1 1 2 1 2 9-2 1 1 1 1 1 2 3 4 1 2 3 4 9-3 TeamSTEPPS 1 1 2 3 2 1 2 3 9-4 1 2 1 2 9-5 ECMO 1 1 1 1 1 1 2 2 1 2 54 1 11 23 6
9-6 1,7 1 1 2 3 4 5 6 7 1 2 3 4 5 6 7 12 00 12 50 BowTie Applying the BowTie risk assessment methodology in healthcare Pieter Weijand (Director of Business Development, BowTieMED) 14 20 15 14 10 1 10-1 10-2 1 2 2 1 2 10-3 1 2 2 2 2 3 4 1 2 3 4 10-4 1 1 1 2 1 2 10-5 KYT 1 2 3 2 4 1 1 2 3 4 10-6 AHA Family & Friends AED 1 2 2 2 3 4 5 1 2 6 1 2 3 4 5 6 BLS 1 11 23 6 55
15 20 16 14 11 2 11-1 11-2 1 2 3 1 2 3 11-3 11-4 1 2 3 1 2 3 11-5 1,2 3 1 2 3 11-6 KYT KYT 16 20 17 14 12 3 12-1 1 2 3 4 3 1 2 3 4 12-2 Face to face 12-3 KYT 3 1 2 3 1 2 3 12-4 12-5 1 1 1 1 1 2 1 2 56 1 11 23 6
12-6 10 1 1 2 1 2 17 20 18 14 13 2 13-1 DVD 13-2 13-3 2 RCA 1 2 2 1 2 13-4 13-5 1 2 1 ( ) 2 13-6 7 TFT 9F 904 6 7 10 00 10 54 14 14-1 1 2 3 1 2 TQM 3 14-2 POCT 1 1 1 1 1 2 3 1 JA 2 JA 3 JA 14-3 ( ) 1 11 23 6 7 57
14-4 1 1 1 2 2 2 1 2 14-5 ACS AMI DPC MDC050030 1 2 1 3 3 1 2 3 14-6 DACS 1 2 2 2 2 3 3 3 3 1 2 3 11 00 11 54 15 15-1 1,2 2 2 2 2 2 1 1 2 1 2 15-2 sky blue 1 1 1 1 2 1 1 1 2 15-3 PCAPS 1 2 4 3 3 1 1 1 1 1 2 3 4 15-4 PCAPS ST 1 1 1 1 1 1 1 1 2 2 1 2 15-5 1 1 1 1 1 2 2 2 1 2 15-6 1 1 2 3 3 4 2,3 1 2 3 4 14 20 15 14 16 1 16-1 58 1 11 23 7
16-2 1,4 2 3 1 1 3,4 4 1 2 3 4 16-3 ME 16-4 1 1 2 3 3 1 2 3 16-5 1 1 1 1 1 1 2 3 3 1 2 3 16-6 1 2 1 1 1 1 3 2 1 2 3 15 20 16 14 17 2 17-1 1 2 1 3 3 1 2 ME 3 17-2 1 2 2 1 2 17-3 1 1 1 1 1 1 2 3 3 1 2 3 17-4 ME 17-5 17-6 1 11 23 7 59
16 20 17 14 18 3 18-1 18-2 18-3 1 1 1 1 1 1 2 2 3 1 2 3 18-4 ME 18-5 18-6 17 20 18 14 19 19-1 19-2 19-3 1 1 1 1 1 1 2 2 3 2 1 2 3 19-4 1 2 2 2 2 2 2 2 2 1 1 2 3 60 1 11 23 7
19-5 19-6 1 2 3 3 4 1 2 3 4 8 TFT 9F 905 7 8 10 00 10 54 20 20-1 3 RAL 20-2 1 2 3 4 5 1 6 1 2 3 4 5 6 20-3 20-4 20-5 1 2 1 1 ) 2 20-6 1 2 2 2 2 2 1 2 11 00 11 45 21 21-1 4 1,3 1 1 1 1 2 1 2 3 1 11 23 7 8 61
21-2 1 24 1 1 1 1,3 1 2 1 2 3 21-3 3 1 1,3 1 1 1 2 1 2 3 21-4 2 21-5 GS1 1 2 3 4 5 6 7 8 9 1 NTT 2 3 4 5 MSD 6 7 8 9 14 20 15 23 22 22-1 22-2 1 1 1 1 2 3 4 5 1 1 1 2 3 4 5 22-3 22-4 1 1,2 1,2 1 3 1 2 3 22-5 e OQT9 1 2 3 4 4 5 6 2 7 1 2 3 4 5 6 7 22-6 2 62 1 11 23 8
22-7 1 15 30 16 24 23 23-1 1 2 2 2 2 2,3 4 1 5 1 2 3 4 5 23-2 1 1 1 1 1 1 2 2 1 1 2 23-3 2009 23-4 1 2 2 1 3 1 2 3 23-5 23-6 1 1 2 1 1 1 2 16 30 17 24 24 24-1 PCAPS 1 2 3 4 4 5 6 1 2 3 4 5 6 24-2 PCAPS 1 1 1 1 2 2 3 3 4 4 1 2 3 4 1 11 23 8 63
24-3 EOG 1 1,2 3 4 4 1 2 3 4 24-4 24-5 24-6 17 30 18 24 25 25-1 - 1 1,2 3 1 4 1 2 3 4 25-2 AHA 1 2 2 2 1 2 25-3 HBs HCV 1 2 1 2 25-4 25-5 1 2 2 1 2 25-6 1 1 1 1 2 3 4 1 2 3 4 64 1 11 23 8