Presentation
Incorporating Equity Considerations Into Serious Safety Event Review Processes
SessionAdverse Events (HE2)
DescriptionPatient safety events (PSEs) describe instances of avoidable harm within healthcare settings, and among these are serious safety events (SSEs) which represent significant patient harm or death [1,2]. From 2022 to 2023, 1 in every 17 hospital stays in Canada result in at least 1 harmful event, which amounted to approximately 146,000 harmful events [3]. Hospital staff report SSEs, which are then reviewed to identify contributing factors and develop interventions that prevent recurrence and enhance safety [4]. Patients from marginalized backgrounds, such as those based on race, religion, gender identity, age, or housing status, face unique risk factors in healthcare systems that contribute to PSEs [4,5]. However, equity concerns are not systematically investigated during SSE review processes as there are no well-defined methods that incorporate these concerns as potential contributors. Additionally, quality improvement (QI) interventions developed to reduce incidents often target general patient populations but may worsen inequities when they do not address risk factors impacting marginalized populations [6]. According to Public Health Ontario, many inequities in healthcare systems are caused by factors such as race/ethnicity, gender, income, social status, education, and physical environment [7]. For example, in Canada there is a disproportionate burden of health inequities and disparities for Indigenous populations compared to non-Indigenous Canadians, which negatively impacts their health status [5]. The planned improvement to help mitigate this issue is the development of an innovative, standardized tool that can be implemented in the SSE review process to consider equity related concerns which may be potential contributors to SSEs.
This project aims to address the gap of a standardized tool to identify potential equity related contributors to SSEs and support investigation during the structured event review process at two hospitals in Toronto. The equity review tool will help the patient safety event committee identify equity related concerns and root causes of SSEs, guiding the development of targeted interventions. The tool will utilize available patient data and incorporate information about various equity concerns to be investigated. The development of a tool that improves the systematic identification of equity issues presents an opportunity to reduce disproportionate harm for marginalized populations [6,9].
In this study, an environmental scan of current approaches utilized to conduct SSE review from an equity lens at healthcare systems will be conducted, to understand which methods are currently being used. Semi-structured interviews will be conducted with hospital staff to collect information about the current SSE review process, how equity is currently being considered during the process if at all, and trends they have observed related to equity issues. Qualitative data analysis of the information obtained will be conductive to identify prevalent themes and issues regarding equity, as well as current pain points in the SSE review process. The themes and pain points identified will be used to inform the design of a standardized approach to incorporate equity considerations into the SSE review process. Simulations of potential approaches will be conducted with mock SSEs to gather feedback and inform an updated iteration. The developed tool will be utilized by the event review committee during the SSE review process for the duration of a three month evaluation period. Additional feedback from the use of the tool during the evaluation period will be used to inform an improved iteration of the selected approach, as well as provide additional recommendations to incorporate equity considerations into the SSE review process.
References
[1] Gong, Yang et al. “Enhancing Patient Safety Event Reporting”. Applied Clinical Informatics. July 2017. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220687/
[2] Donnelly et al. "Creating a Defined Process to Improve the Timeliness of Serious Safety Event Determination and Root Cause Analysis". Pediatric Quality & Safety. August 2019. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831051/
[3] “Patient harm in Canadian hospitals? It does happen.” Canadian Institue for Health Information. 2023. https://www.cihi.ca/en/patient-harm-in-canadian-hospitals-it-does-happen
[4] Adelson, Naomi. "The Embodiment of Inequity: Health Disparities in Aboriginal Canada". Canadian Journal of Public Health. March 2005. Accessed: https://link.springer.com/article/10.1007/BF03403702
[5] Lane-Fall, Meghan. "Why Diversity, Equity, and Inclusion Matter for Patient Safety". ASA Publications. November 2021. Available: https://pubs.asahq.org/monitor/article/85/11/42/117785/Why-Diversity-Equity-and-Inclusion-Matter-for
[6] Green, A.R. et al. "Leveraging Quality Improvement to Achieve Equity in Health Care". The Joint Commission Journal on Quality and Patient Safety. October 2010. Accessed: https://www.sciencedirect.com/science/article/abs/pii/S155372501036065X
[7] "Health Equity". Public Health Ontario. Available: https://www.publichealthontario.ca/en/Health-Topics/Health-Equity#:~:text=Many%20causes%20of%20health%20inequities,health%20promotion%20programs%20and%20policies.
[8] Gosbee J., Anderson T. "Human factors engineering design demonstrations can enlighten your RCA team". BMJ Quality & Safety. Available: https://qualitysafety.bmj.com/content/12/2/119.short [Accessed March 2024]
[9] Thomas et al. "Policy Changes To Address Racial/Ethnic Inequities In Patient Safety". Health Affairs Editorial. February 2022. Available: https://www.healthaffairs.org/content/forefront/policy-changes-address-racial-ethnic-inequities-patient-safety
[10] Cheraghi-Sohi et al. "Patient safety in marginalised groups: a narrative scoping review". International Journal for Equity in Health. 2020. Available: https://link.springer.com/content/pdf/10.1186/s12939-019-1103-2.pdf
[11] Gosbee J., Anderson T. "Human factors engineering design demonstrations can enlighten your RCA team". BMJ Quality & Safety. Available: https://qualitysafety.bmj.com/content/12/2/119.short [Accessed March 2024]
This project aims to address the gap of a standardized tool to identify potential equity related contributors to SSEs and support investigation during the structured event review process at two hospitals in Toronto. The equity review tool will help the patient safety event committee identify equity related concerns and root causes of SSEs, guiding the development of targeted interventions. The tool will utilize available patient data and incorporate information about various equity concerns to be investigated. The development of a tool that improves the systematic identification of equity issues presents an opportunity to reduce disproportionate harm for marginalized populations [6,9].
In this study, an environmental scan of current approaches utilized to conduct SSE review from an equity lens at healthcare systems will be conducted, to understand which methods are currently being used. Semi-structured interviews will be conducted with hospital staff to collect information about the current SSE review process, how equity is currently being considered during the process if at all, and trends they have observed related to equity issues. Qualitative data analysis of the information obtained will be conductive to identify prevalent themes and issues regarding equity, as well as current pain points in the SSE review process. The themes and pain points identified will be used to inform the design of a standardized approach to incorporate equity considerations into the SSE review process. Simulations of potential approaches will be conducted with mock SSEs to gather feedback and inform an updated iteration. The developed tool will be utilized by the event review committee during the SSE review process for the duration of a three month evaluation period. Additional feedback from the use of the tool during the evaluation period will be used to inform an improved iteration of the selected approach, as well as provide additional recommendations to incorporate equity considerations into the SSE review process.
References
[1] Gong, Yang et al. “Enhancing Patient Safety Event Reporting”. Applied Clinical Informatics. July 2017. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220687/
[2] Donnelly et al. "Creating a Defined Process to Improve the Timeliness of Serious Safety Event Determination and Root Cause Analysis". Pediatric Quality & Safety. August 2019. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831051/
[3] “Patient harm in Canadian hospitals? It does happen.” Canadian Institue for Health Information. 2023. https://www.cihi.ca/en/patient-harm-in-canadian-hospitals-it-does-happen
[4] Adelson, Naomi. "The Embodiment of Inequity: Health Disparities in Aboriginal Canada". Canadian Journal of Public Health. March 2005. Accessed: https://link.springer.com/article/10.1007/BF03403702
[5] Lane-Fall, Meghan. "Why Diversity, Equity, and Inclusion Matter for Patient Safety". ASA Publications. November 2021. Available: https://pubs.asahq.org/monitor/article/85/11/42/117785/Why-Diversity-Equity-and-Inclusion-Matter-for
[6] Green, A.R. et al. "Leveraging Quality Improvement to Achieve Equity in Health Care". The Joint Commission Journal on Quality and Patient Safety. October 2010. Accessed: https://www.sciencedirect.com/science/article/abs/pii/S155372501036065X
[7] "Health Equity". Public Health Ontario. Available: https://www.publichealthontario.ca/en/Health-Topics/Health-Equity#:~:text=Many%20causes%20of%20health%20inequities,health%20promotion%20programs%20and%20policies.
[8] Gosbee J., Anderson T. "Human factors engineering design demonstrations can enlighten your RCA team". BMJ Quality & Safety. Available: https://qualitysafety.bmj.com/content/12/2/119.short [Accessed March 2024]
[9] Thomas et al. "Policy Changes To Address Racial/Ethnic Inequities In Patient Safety". Health Affairs Editorial. February 2022. Available: https://www.healthaffairs.org/content/forefront/policy-changes-address-racial-ethnic-inequities-patient-safety
[10] Cheraghi-Sohi et al. "Patient safety in marginalised groups: a narrative scoping review". International Journal for Equity in Health. 2020. Available: https://link.springer.com/content/pdf/10.1186/s12939-019-1103-2.pdf
[11] Gosbee J., Anderson T. "Human factors engineering design demonstrations can enlighten your RCA team". BMJ Quality & Safety. Available: https://qualitysafety.bmj.com/content/12/2/119.short [Accessed March 2024]
Event Type
Oral Presentations
TimeMonday, March 312:15pm - 2:37pm EDT
LocationHarbour C
Hospital Environments (HE)