A Systemwide Strategy to Embed Equity into Patient Safety Event Analysis

Area of Science:

• Healthcare Quality Improvement
• Health Equity Research
• Patient Safety Analysis

Background:

• A gap exists in frameworks for incorporating health equity into patient safety event analysis.
• This quality improvement initiative addressed this gap within a large municipal healthcare system.
• The initiative focused on developing and implementing practical equity tools and training.

Purpose of the Study:

• To develop and evaluate novel tools for embedding equity into patient safety event analysis.
• To assess the impact of a training program on staff knowledge and comfort with health equity in event analysis.
• To measure participant discomfort or distress during the training and tool evaluation.

Main Methods:

• Developed the Patient Equity Wheel and an Embedding Equity in Root Cause Analysis Worksheet.
• Conducted a two-hour interactive, case-based training across 11 acute care facilities.
• Administered pre and post surveys, including a clinical vignette analysis, and a separate tool assessment.

Main Results:

• Participant knowledge and comfort in embedding equity into event analysis significantly increased post-training.
• The most unrecognized bias categories were Training/Competencies, Structural Workflow, and Culture/Norms.
• Tools were adopted system-wide, enhancing health equity conversations during event analysis.

Conclusions:

• The developed equity tools and training are effective in improving health equity integration in patient safety event analysis.
• Staff demonstrated increased capacity to identify and address biases in care.
• The initiative successfully fostered more comprehensive health equity discussions within the healthcare system.