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Learning Session Abstract

Health Literacy-related Safety Events: One Children’s Hospital’s Experience

Gibson, Cori A. MSN, RN, CNL*; Morrison, Andrea K. MD, MS; Gutzeit, Michael F. MD*

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Pediatric Quality and Safety: March/April 2020 - Volume 5 - Issue - p e262
doi: 10.1097/pq9.0000000000000262
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Communication gaps leading to misunderstandings in medications, care plans, or health information can compromise patient safety. Focusing on health literate communication improves patient outcomes; however, many gaps in communication exist across healthcare. It is not known what deficits in health literate communication lead to patient safety events.


Our aims were to (1) describe health literate communication themes identified in patient safety events and (2) identify health literacy-related areas for improving patient safety.


The safety events entered into a system-wide self-reported safety event collection database were prospectively tagged for health literacy events by a safety specialist trained in health literacy. The database was retrospectively queried for all health literacy tagged events in 9 months (September 2017–May 2018). The authors reviewed and independently coded health literacy-associated safety events. Qualitative content analysis of events facilitated by NVivo was completed to identify the health literacy-related safety event themes.


Health literacy events comprised 4% (156/3,911) of self-reported safety events during the 9 months. Main themes of the health literacy safety events related to (1) medication; (2) discharge/transition; and (3) other health system events (Table 1). Subthemes of each of the events further described the event types. Health literacy-associated safety events were connected to all types of safety event outcomes (near miss, precursor, and serious safety events).

Table 1.:
Health Literacy-related Safety Event Themes


Health literacy-related safety events occur in the healthcare environment and impact all types of safety event outcomes. Lack of health-literate practices impacts patient safety for patient/parent understanding of: (1) medication; (2) discharge/transition; and (3) health systems issues. Though health literacy-related safety events comprise a small number of overall safety events reported, this is likely an underestimate due to the self-reported nature of events, especially those types of events that a parent or staff has to recognize as a communication failure. Future work to improve patient safety outcomes can draw from these events and use health literacy-related interventions to improve communication, especially around medications, verbal communication, and transitions of care.

Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.