Transparent representation of safety activities in a patient care pathway

Care pathways plan out the expected course of patient treatment. As well as reducing clinical variations their use supports healthcare teams with regard to recognizing and implementing evidence-based key interventions. In this contribution it is proposed that event tree diagrams, an inductive safety analysis technique traditionally used to represent possible accident sequences, can also be used to represent safety activities within an operational care pathway. Used qualitatively such a diagram provides a transparent representation of the important control actions and monitoring activities that contribute directly to safety. Quantifying the different elements of the event tree diagram, using continuously collected error data, provides an overview of the current performance of individual elements as well as the whole of a pathway. To demonstrate this capability event trees are used to provide a transparent representation of safety activities within two computerized prescriber order entry medication systems.