Educational Material

[Article]How to use the bow-tie diagram in risk analysis and management

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The bow-tie diagram is a graphical method used to analyze and manage risks in various areas such as safety, occupational health, environment, engineering, and health. The name comes from the bow-tie format that the diagram takes when drawn. It is made up of an unwanted event in the center with lines extending outwards, representing the threats and consequences of that event.

The use of the diagram in patient safety risk analysis is a widely used approach and is considered effective for identifying, understanding, and mitigating risks related to healthcare. It is a visual tool that helps map the threats and consequences of adverse events, as well as the existing control measures necessary to prevent or mitigate them.

The bow-tie diagram covers all stages of the risk management cycle, from hazard identification to risk analysis, assessment, and control. Thus, the methodology provides a comprehensive view of an adverse event scenario.

The tool can be applied to patient safety as follows:

  • IDENTIFICATION OF THE ADVERSE EVENT: in the center of the diagram, place the specific adverse event that you want to analyze, such as medication errors, patient falls, hospital infections, surgical errors, among others;
  • THREATS: threats that contribute to the undesired event are identified and listed to the left of the central event. These threats can include human factors, communication failures, lack of training, infrastructure problems, among others;
  • PREVENTION CONTROL: lines are drawn to the left of the undesired event to represent existing control measures. These barriers may be policies, procedures, protocols, technologies, or any other measures adopted to prevent the unwanted event;
  • CONSEQUENCES: the direct consequences of the unwanted event are identified and listed on the right of the diagram, including damage to the patient, worsening of health status, prolongation of hospitalization, negative perception of the patient and family, among others;
  • RECOVERY CONTROL: lines can be added to represent the recovery control measures necessary to prevent or mitigate the consequences, including process improvements, additional training, use of security technologies, among other preventive actions.

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