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Inpatient patient safety events in vulnerable populations: a retrospective cohort study
  1. Lucy B Schulson1,2,
  2. Victor Novack3,4,
  3. Patricia H Folcarelli5,6,
  4. Jennifer P Stevens3,7,
  5. Bruce E Landon3,6,8
  1. 1General Internal Medicine, Boston Medical Center, Boston, MA, USA
  2. 2The RAND Corportation, Boston, MA, USA
  3. 3Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
  4. 4Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
  5. 5Health Care Quality, Beth Israel Deaconess Medical Center, Boston, MA, USA
  6. 6Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA, USA
  7. 7Division for Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
  8. 8Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
  1. Correspondence to Dr Lucy B Schulson, RAND Corp Boston office, Boston MA 02116, USA; schulson{at}


Background Widespread attention to structural racism has heightened interest in disparities in the quality of care delivered to racial/ethnic minorities and other vulnerable populations. These groups may also be at increased risk of patient safety events.

Objective To examine differences in inpatient patient safety events for vulnerable populations defined by race/ethnicity, insurance status and limited English proficiency (LEP).

Design Retrospective cohort study.

Setting Single tertiary care academic medical centre.

Participants Inpatient admissions of those aged ≥18 years from 1 October 2014 to 31 December 2018.

Measurements Primary exposures of interest were self-identified race/ethnicity, Medicaid insurance/uninsured and LEP. The primary outcome of interest was the total number of patient safety events, defined as any event identified by a modified version of the Institute for Healthcare Improvement global trigger tool that automatically identifies patient safety events (‘automated’) from the electronic record or by the hospital-wide voluntary provider reporting system (‘voluntary’). Negative binomial models were used to adjust for demographic and clinical factors. We also stratified results by automated and voluntary.

Results We studied 141 877 hospitalisations, of which 13.6% had any patient safety event. In adjusted analyses, Asian race/ethnicity was associated with a lower event rate (incident rate ratio (IRR) 0.89, 95% CI 0.83 to 0.96); LEP patients had a lower risk of any patient safety event and voluntary events (IRR 0.91, 95% CI 0.87 to 0.96; IRR 0.89, 95% CI 0.85 to 0.94). Asian and Latino race/ethnicity were also associated with a lower rate of voluntary events but no difference in risk of automated events. Black race was associated with an increased risk of automated events (IRR 1.11, 95% CI 1.03 to 1.20).

Limitations This is a single centre study.

Conclusions A commonly used method for monitoring patient safety problems, namely voluntary incident reporting, may underdetect safety events in vulnerable populations.

  • patient safety
  • incident reporting
  • hospital medicine

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  • Contributors Conception: all authors. Data acquisition: LS, JPS. Data analysis and interpretation: LS, VN and BL. Drafting the article: LS and BL. Critical revision of the article: all authors. Final approval of the version to be published: all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Institutional Review Board at Beth Israel Deaconess Medical Center.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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