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This article was written by Angela D. Thomas, DrPH, MPH, MBA.
Recently published research from MedStar Health Research Institute demonstrates the connection between racial bias and under-reporting of patient safety events and outlines the action steps needed to improve equity in patient safety and reporting.
Dozens of studies have identified inequities in how people from different racial or ethnic backgrounds experience healthcare in the U.S. And most of the research has identified disparities that lead to adverse outcomes for people from minoritized communities:
- According to the U.S. Centers for Disease Control and Prevention (CDC), the average life expectancy for a Black or African American person in 2019 was four years shorter than for a White person. This can be partly explained by disparities in health fairness or equity.
- Nationwide, people in minoritized racial and ethnic groups experience higher rates of disease and ill health than White people. This includes conditions like diabetes, high blood pressure, obesity, asthma, heart disease, cancer, and preterm birth.
While most studies end with a list of “what should be done,” recently published research by MedStar Health Research Institute and our collaborators at RAND Corporation, with funding from the California Health Care Foundation, provides actionable steps to get things done.
We used two complementary research methods to thoroughly understand how disparities impact patient safety. First, we completed an environmental scan of all the available literature on the topic. Then, we conducted qualitative interviews with clinicians who are health equity or patient safety experts.
The resulting publication is a deep dive into how disparities impact patient safety, reporting, and outcomes—and how healthcare systems can help address specific problems to reduce the impact of racism on patient outcomes.
Read up: Finding gaps in data and reporting.
Our review of literature on racism and patient safety included peer-reviewed studies, editorials, commentaries, blog posts, and gray literature—information is produced outside the usual scholarly publishing framework.
Many health systems do not collect data on race, ethnicity, or preferred language when reporting patient safety events. In rare cases where this information is collected, patient safety events remain underreported.
Comparing patient safety data among racial or ethnic groups is critical to identifying bias in patient safety events. Considering patient safety data in the aggregate can only mask issues that may be occurring in specific populations.
It may appear, for instance, that a health system’s patients with high blood pressure are being well-cared for when the data is reviewed in the aggregate. Filtering by race or ethnicity could reveal that while White patients have their hypertension under control, Black patients are struggling.
Racial bias may be one explanation for this discrepancy. A provider must be comfortable speaking up to report a patient safety event. Studies show that providers who identify with a minoritized group may be less comfortable bringing up events\ because of their own experiences with racism.
In 2017, MedStar Health Research Institute examined disparities in reporting patient safety events. We concluded safety events reports are recorded more often when the patients involved were White. This was corroborated during our recent interviews with healthcare providers, who also highlighted several other important considerations.
Let’s talk: Interviews with experienced clinicians.
In spring 2022, our researchers held interviews with clinicians who have patient safety or health equity experience. These 60-minute, semi-structured interviews were conducted online and covered topics including the clinician’s background, factors related to patient safety events and reporting, and the impact of racism on patient safety.
The subject matter experts agreed that racism could increase the risk of patient safety events, and they expressed a range of viewpoints on its level of impact.
They noted that biases could affect where patients receive care, leading to disparities in quality, delayed care, and risk of developing comorbidities. Some cited longstanding systemic racism embedded in medical school curricula—such as learning about skin diseases only on light skin—which can lead to the misdiagnosis of patients with darker pigmentation. One interviewee noted that “racism is so embedded, it impacts everything.”
Based on the review of literature and themes that surfaced during interviews, several levels of racism and associated effects on patient safety emerged:
- Systemic: Ongoing racial inequities maintained by society. For example, lack of access to high-quality healthcare facilities because of social policies such as redlining, the practice of withholding financial and other services based on race or ethnicity.
- Institutional: Discriminatory policies and practices within organizations. Healthcare institutions may fail to collect race information in patient safety data platforms, giving no opportunity to identify and mitigate potential disparities.
- Interpersonal: Biases between individuals through words and action. For example, a provider dismisses a patient’s concerns because of bias leads to a missed or delayed diagnosis.
- Internalized: Race-based personal beliefs. For example, they are not speaking up about a safety event due to their feelings about how certain people should be treated or out of concern that no one will listen because of their past experiences.
Understanding the types of racism patients and providers experience is a start to improving patient safety disparities. The next step is putting that understanding into action.
Four immediate steps to turn research into action.
Responsibility for the persistence of racial biases does not lie with one person or group. It is incumbent upon everyone at every level of patient care to work together toward achieving our goal of zero harm.
Our study identified four primary recommendations to help combat the influence of racism on patient safety. Thanks to the commitment of our leadership at MedStar Health, we are working to put these recommendations into practice.
1. Implement an equity approach to patient safety data collection.
Failing to collect data on race, ethnicity, and other patient characteristics in patient safety reports creates barriers to identifying disparities and inequities and silently contributes to systemic racism.
2. Improve the user experience in formal reporting systems.
All formal reporting systems that log patient safety events should encourage consistent, efficient, and thorough use—and integrate with electronic medical records. Regulators should work to implement national usability standards for these reporting systems and apply incentives for health systems that adopt and adhere to these policies.
At MedStar Health, National Center for Human Factors in Healthcare scholars can apply such techniques to analyze the usability of electronic records systems. This cost-effective tool identifies opportunities to improve reporting software to reduce physician burnout and benefit patient safety.
3. Create a culture of speaking up.
Efforts to understand and eliminate racism in patient safety must begin with strong leadership committed to equity, diverse leadership, and a workforce in which all voices are heard and respected. Health systems should empower patients by embedding patient advocates throughout care settings and require the use of interpreters when needed for a patient’s preferred language.
At MedStar Health, we’re committed to working towards this vision. Under the leadership of Vice President for Equity, Inclusion, and Diversity Sandy Johnson Harris and Vice President for Quality and Safety Dr. Terry Fairbanks, we have made strides towards prioritizing patient safety and equity, and have made an incredible commitment to addressing these recommendations close to home.
4. Revise outdated medical education content.
Regulators should require changes in medical education to remove racist curricula and teach race as a social construct.
Bonus recommendation: Slow down and listen to patients.
Research has shown that people who are stressed and working in under-resourced environments—like many hospitals and clinics—are more likely to be influenced by unconscious biases. Moving quickly from patient to patient opens opportunities for superficial decisions based on limited information.
To reduce this risk, we recommend providers take extra time to talk with patients about their health challenges and personal needs. Factors that influence health, such as the toll of caretaking for a family member or spouse, can be revealed in day-to-day realities. Learning a patient’s story can help providers work through implicit biases and assumptions that can creep in when speed is of the essence.
Where do we go from here.
As researchers, we know there’s value in pointing out that issues exist. But showing is not enough—we are focused on doing.
Our next steps include going out into the field to identify best practices that are already underway. With this information, we plan to develop a toolkit all healthcare systems can use to help address patient safety and racial bias. We’ll provide tangible tools and guidance for healthcare leadership to help them transform these recommendations into reality.
Our goal is to build the tools people need to make a tangible impact on how minoritized people interact with the healthcare system, thereby reducing patient safety events and improving outcomes for everyone.
We believe we can achieve our goal of zero harm through collective effort.
