Race Differences in Reported Harmful Patient Safety Events in Healthcare System High Reliability Organizations

A Coproduced Family Reporting Intervention to Improve Safety Surveillance and Reduce Disparities

OBJECTIVES

Examine family safety-reporting after implementing a parent-nurse-physician-leader coproduced, health literacy-informed, family safety-reporting intervention for hospitalized families of children with medical complexity.

METHODS

We implemented an English and Spanish mobile family-safety-reporting tool, staff and family education, and process for sharing comments with unit leaders on a dedicated inpatient complex care service at a pediatric hospital. Families shared safety concerns via predischarge surveys (baseline and intervention) and mobile tool (intervention). Three physicians with patient safety expertise classified events. We compared safety-reporting baseline (via survey) versus intervention (via survey and/or mobile tool) with generalized estimating equations and sub-analyzed data by COVID-19-era and educational attainment. We also compared mobile tool-detected event rates with hospital voluntary incident reporting.

RESULTS

232 baseline and 208 intervention parents participated (78.2% consented); 29.5% of baseline families versus 38.2% of intervention families reported safety concerns (P = .09). Adjusted odds ratio (95% CI) of families reporting safety concerns intervention versus baseline was 1.6 (1.0-2.6) overall, 2.6 (1.3-5.4) for those with < college education, and 3.1 (1.3-7.3) in the COVID-19-era subgroup. Safety concerns reported via mobile tool (34.6% of enrolled parents) included 42 medical errors, 43 nonsafety-related quality issues, 11 hazards, and 4 other. 15% of mobile tool concerns were also detected with voluntary incident reporting.

CONCLUSIONS

Family safety-reporting was unchanged overall after implementing a mobile reporting tool, though reporting increased among families with lower educational attainment and during the COVID-19 pandemic. The tool identified many events not otherwise captured by staff-only voluntary incident reporting. Hospitals should proactively engage families in reporting to improve safety, quality, and equity.

Nurse judgements of hospitalized patients' safety concerns are affected by patient, nurse and event characteristics: A factorial survey experiment

AIM

To test the influences of patient, safety event and nurse characteristics on nurse judgements of credibility, importance and intent to report patients' safety concerns.

DESIGN

Factorial survey experiment.

METHODS

A total of 240 nurses were recruited and completed an online survey including demographic information and responses to eight factorial vignettes consisting of unique combinations of eight patient and event factors. Hierarchical multivariate analysis was used to test influences of vignette factors and nurse characteristics on nurse judgements.

RESULTS

The intraclass coefficients for nurse judgements suggest that the variation among nurses exceeded the influence of contextual vignette factors. Several significant sources of nurse variation were identified, including race/ethnicity, suggesting a complex relationship between nurses' characteristics and their potential biases, and the influence of personal and patient factors on nurses' judgements, including the decision to report safety concerns.

CONCLUSION

Nurses are key players in the system to manage patient safety concerns. Variation among nurses and how they respond to scenarios of patient safety concerns highlight the need for nurse-level intervention.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Complex factors influence nurses' judgement, interpretation and reporting of patients' safety concerns.

IMPACT

Understanding nurse judgement regarding patient-expressed safety concerns is critical for designing processes and systems that promote reporting. Multiple event and patient characteristics (type of event and apparent harm, and patient gender, race/ethnicity, socioeconomic status, and communication approach) as well as participant characteristics (race/ethnicity, gender, years of experience and primary hospital area) impacted participants' judgements of credibility, degree of concern and intent to report. These findings will help guide patient safety nurse education and training.

REPORTING METHOD

STROBE guidelines.

PATIENT OR PUBLIC CONTRIBUTION

Members of the public, including patient advocates, were involved in content validation of the vignette scenarios, norming photographs used in the factorial survey and testing the survey functionality.

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports

BACKGROUND

Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports.

METHODS

The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated.

RESULTS

Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54).

CONCLUSION

Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey

BACKGROUND

Language barrier, reduced self-advocacy, lower health literacy or biased care may hinder the diagnostic process. Data on how patients/families with limited English-language health literacy (LEHL) or disadvantaged socioeconomic position (dSEP) experience diagnostic errors are sparse.

METHOD

We compared patient-reported diagnostic errors, contributing factors and impacts between respondents with LEHL or dSEP and their counterparts in the 2017 Institute for Healthcare Improvement US population-based survey, using contingency analysis and multivariable logistic regression models for the analyses.

RESULTS

596 respondents reported a diagnostic error; among these, 381 reported LEHL or dSEP. After adjusting for sex, race/ethnicity and physical health, individuals with LEHL/dSEP were more likely than their counterparts to report unique contributing factors: "(No) qualified translator or healthcare provider that spoke (the patient's) language" (OR and 95% CI 4.4 (1.3 to 14.9)); "not understanding the follow-up plan" (1.9 (1.1 to 3.1)); "too many providers… but no clear leader" (1.8 (1.2 to 2.7)); "not able to keep follow-up appointments" (1.9 (1.1 to 3.2)); "not being able to pay for necessary medical care" (2.5 (1.4 to 4.4)) and "out-of-date or incorrect medical records" (2.6 (1.4 to 4.8)). Participants with LEHL/dSEP were more likely to report long-term emotional, financial and relational impacts, compared with their counterparts. Subgroup analysis (LEHL-only and dSEP-only participants) showed similar results.

CONCLUSIONS

Individuals with LEHL or dSEP identified unique and actionable contributing factors to diagnostic errors. Interpreter access should be viewed as a diagnostic safety imperative, social determinants affecting care access/affordability should be routinely addressed as part of the diagnostic process and patients/families should be encouraged to access and update their medical records. The frequent and disproportionate long-term impacts from self-reported diagnostic error among LEHL/dSEP patients/families raises urgency for greater prevention and supportive efforts.

Applying an equity lens to hospital safety monitoring: a critical interpretive synthesis protocol

INTRODUCTION

Hospital safety monitoring systems are foundational to how adverse events are identified and addressed. They are well positioned to bring equity-related safety issues to the forefront for action. However, there is uncertainty about how they have been, and can be, used to achieve this goal. We will undertake a critical interpretive synthesis (CIS) to examine how equity is integrated into hospital safety monitoring systems.

METHODS AND ANALYSIS

This review will follow CIS principles. Our initial compass question is: How is equity integrated into safety monitoring systems? We will begin with a structured search strategy of hospital safety monitoring systems in CINAHL, EMBASE, MEDLINE and PsycINFO for up to May 2023 to identify papers on safety monitoring systems generally and those linked to equity (eg, racism, social determinants of health). We will also review reference lists of selected papers, contact experts and draw on team expertise. For subsequent literature searching stages, we will use team expertise and expert contacts to purposively search the social science, humanities and health services research literature to support the development of a theoretical understanding of our topic. Following data extraction, we will use interpretive processes to develop themes and a critique of the literature. The above processes of question formulation, article search and selection, data extraction, and critique and synthesis will be iterative and interactive with the goal to develop a theoretical understanding of equity in hospital monitoring systems that will have practice-based implications.

ETHICS AND DISSEMINATION

This review does not require ethical approval because we are reviewing published literature. We aim to publish findings in a peer-reviewed journal and present at conferences.

Race Differences in a Malpractice Event Database in a Large Healthcare System

OBJECTIVES

This study aimed to determine whether potential malpractice events reported by employees, malpractice events involving claims, and malpractice lawsuits differ based on patient race in a large 10-hospital healthcare system.

METHODS

Data in a healthcare system's malpractice database from July 1, 2012, to June 30, 2017, were stratified by patient race using "Black," "White," and "other" categories. χ2 Goodness-of-fit tests were used to compare differences in race proportions in employee-reported observations of events that could lead to payment of a claim, claims not involving the court, and lawsuits involving the court.

RESULTS

There were significantly more employee-reported observations and claims for White patients and significantly fewer observations and claims for Black patients than expected based on the race proportions in the overall healthcare system patient population ( P < 0.001). There were no significant race differences in lawsuits (Black patients, P = 0.146; White patients, P = 0.061; other patients, P = 0.458). Four of the 10 hospitals in the healthcare system had significant race differences in potential malpractice events (hospital A, P < 0.001; hospital B, P = 0.011; hospital E, P < 0.001; hospital G, P = 0.010).

CONCLUSIONS

Our findings reveal the existence of race differences in potential malpractice events in a large healthcare system. By proactively investigating, understanding, and addressing racial disparities in patient safety events, including those recorded in malpractice databases, healthcare systems can help advance initiatives to provide high-quality and equitable care to patients.

Race Differences in Reported "Near Miss" Patient Safety Events in Health Care System High Reliability Organizations

OBJECTIVES

This study aimed to determine if race differences exist in voluntarily reported near-miss patient safety events in a large integrated, 10-hospital health care system on its journey to become a high reliability organization.

METHODS

From July 1, 2015, to June 30, 2017, employees in a mid-Atlantic health care system voluntarily reported near-miss events by type using an occurrence reporting system referred to as the Patient Safety Event Management System. Inpatients, outpatients, and observation patients were identified as "Black," "White," or "other" (n = 39,390). Using retrospective analysis and χ2 goodness of fit, comparisons of race proportions were conducted to determine differences at the health system level, by hospital, and by event type.

RESULTS

Significant race differences existed: (1) overall across the health care system with higher proportions of events reported for Whites and lower proportions of events reported for Blacks in the Patient Safety Event Management System, (2) by site in 9 of 10 hospitals, and (3) by type. All differences were significant at P < 0.05.

CONCLUSIONS

Race differences in near-miss patient safety events exist in voluntary reporting systems by type. Health care organizations, particularly health care high reliability organizations, can use these findings to help to identify areas of further study and investigation. Further study and investigation should include efforts to understand the root cause of the differences found in this study, including the role of reporting bias by race.