Pilot Implementation of a Health Equity Checklist to Improve the Identification of Equity-Related Adverse Events

In assessing the occurrence of an unexpected medical adverse event following pharmaceutical, medical, or surgical treatment, the causal or contributory roles played by bias, systemic racism, and social determinants of health should be investigated. Up to 80% of clinical outcomes are estimated to be driven by social determinants including the environments in which patients live, work, learn, worship, and play. Among women, there are racial health disparities in sterilization procedures, method of hysterectomy, cesarean birth rates, preterm birth rates, and, most recently, the rates of COVID-19 death and hospitalizations. At the same time, there is little specific guidance of how to investigate social determinants of health that affect patient outcomes. Differences in health equity-related factors affect the quality of gynecologic care. There is immeasurable potential for bias in patient characteristics: race; ethnicity; persons with obesity; LGBTQ+ (lesbian, gay, bisexual, transgender, queer+) persons; socioeconomic factors; and young and old age. Within existing models for patient safety, inclusion of equity-related aspects of care may improve the current understanding of the causes of medical adverse events. It is critical to consider social determinants of health, structural racism, and both overt and implicit bias. The aim of this study was to establish a sustainable and trackable process to determine the role of social determinants of health, bias, and racism in adverse gynecologic events. Each adverse event case is assessed for preventability, harm, and standards of care. Cases are identified for review utilizing existing hospital event-reporting systems (RLDatix) and enhanced by resident and attending physician self-reporting. The following equity-focused process was used: (1) creating a standardized health equity checklist; (2) applying the checklist to each gynecologic adverse event beginning on September 1, 2020; (3) collecting event review data in a secure central digital repository; (4) reviewing each adverse case to understand apparent causes of the event; (5) exploring areas for improvement using standard fields; and (6) identifying specific ideas for improvement. Within 15 months (between September 1, 2020, and November 30, 2021), 46 safety cases were identified using standard criteria. Twenty-four of these were deemed preventable. Of the 24 cases, 12 cases were identified in which social determinants of health, bias, or both had a role. Delays in diagnosis and care were attributed to social determinants of health and implicit bias. This process has mapped areas of infrastructure as well as the need for culture improvement and restorative work to address implicit bias and improve approaches to shared decision-making. These findings show that with use of a health equity checklist, it is feasible to create a systematic and trackable process to begin delineating the role of social determinants of health, bias, and racism in adverse gynecologic events.

Automated summary

When evaluating unexpected medical adverse events after pharmaceutical, medical, or surgical treatment, it is important to investigate the roles of bias, systemic racism, and social determinants of health. Social determinants of health, including living environments, have a significant impact on clinical outcomes. Racial health disparities exist in various gynecologic procedures and outcomes, and investigating social determinants of health affecting patient outcomes is crucial. This study established a systematic and trackable process to determine the role of social determinants of health, bias, and racism in adverse gynecologic events.