Assessing bias in patient safety reporting systems

by Roxanna Van Norman
July 18, 2022

study by a team of researchers at the Stanford School of Medicine suggests that bias may be present in patient safety reporting systems (PSRSs), a method for reporting incidents related to medical errors that can result in harm to patients.

In a qualitative study of 401 patient safety reports, the researchers assessed whether there was bias in how events were reported based on the race and ethnicity, gender, and faculty rank of the individual who was the subject of the event report.

"What stood out [from the study] is that there is a pattern of reporting female physicians and physicians of racial/ethnic minority for issues of lower severity than male physicians and white physicians," said Yvonne Maldonado, MD, the Senior Associate Dean for Faculty Development and Diversity and the Taube Professor of Global Health and Infectious Diseases and Professor of Pediatrics (Infectious Diseases) and of Epidemiology and Population Health. 

That is, reports for lower severity issues, including inappropriate communication, lack of communication, or conversational issues, were disproportionally associated with female physicians and physicians from racial and ethnic minority groups.

"This finding suggests that reporters may have a lower threshold for what they consider acceptable behavior from a minority physician than they do for a white or male physician," said Maldonado.

These findings suggest that bias may be present in PSRSs, which could impact the career advancements of female physicians and physicians who are members of racial and ethnic minority groups.

Applying DEI lens

PSRSs aim to identify and reduce the risk of patient harm due to medical errors and rely on the individuals in the events to provide detailed information voluntarily. While individuals may report any events or behaviors, the study points out that PSRSs are subject to reporting bias.

"Health care systems are well-intentioned in their commitment to patient safety, but many have not critically examined how implicit bias in long-standing operational systems compromises the patient experience," said Elan Burton, MD, MHA, Clinical Assistant Professor in the Department of Cardiothoracic Surgery and the study's lead author. "Findings from this study underscore the importance of using a diversity, equity, and inclusion lens when creating and implementing provider or patient-centered systems."

The team evaluated reports from March 2011 to February 2020 and coded each event report by theme and severity (on a scale of 1 to 3, with 1 being the lowest and 3 the highest). The reports were analyzed and categorized by physician gender, race and ethnicity, and faculty rank.

Citing previous literature on discrimination experienced by physicians, the study noted there might be a level of implicit bias in communications with female, Black, or Asian physicians, including being subject to different standards and negative stereotyping. Findings showed a disproportionate number of reports among female physicians and physicians who were members of racial and ethnic minority groups for communication problems and lower severity. 

The study focused on Stanford Alert For Events (SAFE) reports, the PSRS used at Stanford Health Care. These SAFE reports can be considered when making recommendations in the promotion process for faculty.

Identifying potential biases

Given the potential for reporting biases in PSRSs, the authors suggest future studies to examine PSRSs at other institutions and evaluate different processes that facilitate communication issues, reduce implicit bias, and foster cohesive working relationships. 

Stanford Medicine is committed to creating a diverse and inclusive environment, Maldonado said, one that is supportive and promotes success for faculty across all social identities. She believes the research study accomplishes one of the first steps in fostering a supportive work environment.

"[The study] has identified a potential barrier for career advancement. If minority physicians disproportionately face excessive scrutiny, it can negatively impact recommendations in promotion processes," said Maldonado. 

Several limitations exist in this study, including the study being of a single academic institution's PSRS. Maldonado hopes to see other institutions replicate similar studies on their patient safety reporting systems to uncover potential biases.

"Another hope is that institutions take action to help university community members unlearn internalized biases or create structured reporting systems that minimize the ability for reporters to rely on our biases, addressing the problem at the root, and perhaps re-think how PSRSs are used," said Maldonado.

Authors of the paper include: Magali Fassiotto, PhD, Associate Dean for Faculty Development and Diversity in Stanford Medicine's Office of Faculty Development and Diversity (OFDD); Brenda Flores, Research and Program Manager for OFDD; Michael Baiocchi, PhD, Associate Professor of Epidemiology and Population Health; and Yan Min, MS, a graduate student in the Department of Epidemiology and Population Health.

Findings from the study were published in JAMA in May 2022.

Elan Burton, MD, MHA

Yvonne Maldonado, MD