Incorporating Equity Considerations into Serious Safety Event (SSE) Review Processes

Patient 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. SSEs are reported by staff and undergo review to investigate factors contributing to the events and develop interventions to prevent recurrence and improve safety. Patients from marginalized backgrounds face unique risks factors in healthcare systems that contribute to PSEs. However, equity concerns are not systematically investigated during SSE review processes as there are no well-defined methods which incorporate these concerns as potential contributors. This project aims to address the gap of a standardized tool to identify potential equity related contributors to SSEs during the event review process at Unity Health and Michael Garron Hospital. We will conduct semi-structured interviews with hospital staff to map current processes, observations of the current SSE review process, and identify the prevalent equity concerns at both institutions and from the literature. This information will be used to inform the development of an equity review tool for the SSE review process. Simulations of the SSE review process will be conducted with event review staff using the designed tool to collect feedback, as well as a three month evaluation trial period. Data collected will be utilized to improve the usability and effectiveness of the design.

Faculty Supervisor:

Myrtede Alfred

Student:

Partner:

Unity Health Toronto

Discipline:

Engineering

Sector:

Health and Related Sciences & Technology

University:

University of Toronto

Program: