Publication Date




Download Full Text (329 KB)


Background: We have long known that various social determinants of health (SDH) such as race, gender, socioeconomic status and others can affect health outcomes, such as readmission rates and mortality. To our knowledge, the impact of SDH on safety events has not been studied.

Objective: We sought to understand the role that social determinants may play in contributing to safety events at our institution and to incorporate this information into the creation of corrective action items following the serious safety event.

Design/Methods: The Clinical Safety team partnered with the Office of Equity and Diversity to develop a standard question regarding the potential influence of any SDH to be asked of each staff member interviewed after a potential serious safety event. The question was asked at the end of the interview and was read to maintain consistency. The question was modified early in the process based on feedback from the interviewers and the staff interviewed. All identified factors were collected, and the clinical safety team ultimately determined the likelihood that factors contributed to the adverse outcomes.

Results: Over the first two and a half years, 129 interviews were conducted spanning 20 safety events. The question was asked in 101 (78%) of the interviews. It was asked more consistently as the project went on, with only 58% in interviewees being asked the first year and 90% thereafter. At least one social determinant was identified as potentially contributing to the safety event in 21 interviews (11 cases). In these cases, an average of 1.36 factors were identified (range 1-3). Language and socioeconomic status were the most frequently identified factors. Responses to the social determinants question were then considered throughout the Root Cause Analysis process, including the development of action items.

Conclusion(s): By treating health equity as fundamental to patient safety, we integrated a question on the potential impact of SDH on safety events. Socialization to the process took time, but staff have now expressed increased awareness of the potential effects of social determinants. The consideration of impact of SDH on adverse events has informed the improvement team in their development of action items. The success of this project has led to the incorporation of health equity questions into other areas, including Performance Improvement, Evidence Based Practice, Patient Family Experience, and others. We hope to incorporate a similar question into the overall event reporting system to help inform future initiatives.

Presented at the 2021 PAS Virtual Conference


Patient Safety | Pediatrics

Assessing the Effects of Social Determinants on Serious Safety Events