B3: In the footsteps of patients: using Systems Thinking to explore safety across patient trajectories


Thursday 11 April 2024 | 13:15–14:30


Format: Workshop 


Stream: Safety


Content filters: Recommended for those working at system level in QI


In this session, we will discuss the use of different frameworks and methods to explore quality and safety across the continuum of care. System thinking and learning are the pillars of quality and safety but often simplistic tools and methods are used to measure and study quality.  Measurement of single predefined elements may be too narrow if we want to understand the quality of a patient trajectory. We will discuss the pros and cons of process-mapping and the AHRQ Dx checklist to explore and identify unintended risk, gaps, and waste.  We will present findings of a review of 80 cross-sectorial cases that were mapped and explored 18 months prior to amputation.


As a result of this session, participants will be able to:



  • Describe the elements in a cross-sectorial analysis of a patient trajectory

  • Discuss pros and cons in selecting methods to measure and study risk, safety and quality in cross-sectorial cases

  • List ways to apply different frameworks into their own practice


Louise Weile Region of Zealand, Denmark


Vibeke Rischel PS! Danish Society for Patient Safety, Denmark