Incorporating Equity Considerations Into Serious Safety Event Review Processes

Serious safety events (SSEs) are a subset of patient safety events (PSEs) reported in hospitals which results in a severe level of harm. Many of these events are cases of avoidable harm and are investigated during SSE review processes. Systemic inequities are prevalent in healthcare systems and contribute to the occurrence of SSEs, however are frequently overlooked due to the absence of a standardized investigative approach. In this study, semi-structured interviews will be conducted with hospital staff to understand the SSE review process and investigate inequities. Data will be used to develop a standardized approach to consider equity in the SSE review process. Simulations will be conducted during the design process with potential approaches, and feedback will be utilized to iterate the tool. The tool will be evaluated by use of the event review committee over a three month period, and results will be utilized to inform the final design. There is currently no standardized approach to investigate inequity in the SSE review process at the organization, and therefore the designed approach will improve the current process to be able identify these issues, and flag them as potential contributors to SSEs which will result in these issues being recognized as well as addressed through appropriate interventions. This will result in systemic change at the hospital and increased patient safety, especially for marginalized populations.??

Faculty Supervisor:

Myrtede Alfred

Student:

Partner:

Unity Health Toronto

Discipline:

Engineering

Sector:

Health and Related Sciences & Technology

University:

University of Toronto

Program: