Public safety flags in medical records – the text, subtext, and repercussions

Boston Medical Center

“Assaultive: Patient attempted to strike a nurse in the face with his fist. Plan: Notify Public Safety when patient is present for treatment or services. Public Safety will work collaboratively with clinical/administrative staff to determine appropriate action plan (i.e. patient-safety search, extra patrols, short-post, etc.) when at all practical.”

This could have been my father. In a fit of delirium near the end of many years struggling with early onset Alzheimer’s disease, he was uncharacteristically assaultive to my mother during one of her visits, pushing her to the ground and pulling her hair. I don’t know if a similar public safety alert is highlighted in yellow in the corner of my father’s hospital chart, but it stung to read the alert about my patient, Mr. S, and imagine the assumptions another provider might arrive upon when scanning the chart. Or to envision a random “patient-safety search” launched against Mr. S at an outpatient follow-up visit.

Like my father, Mr. S was a gentle giant with an easy-going and humble air about him. That was until sepsis, strokes, and uremia from missing dialysis due to line access issues left him utterly confused about his surroundings and distressed to the point of trying to flee, culminating in the aforementioned event. Thankfully, a combination of antibiotics and hemodialysis delivered Mr. S out of his delirious agitation within a day or two. But I worried that this written notification could have longstanding and potentially dangerous health effects for Mr. S.

I did not have the same concerns for my father. My father was a white man and Mr. S is a Black man. My parents and I have had the privilege of navigating the hospital system and the outside world without constant concerns about being mislabeled as public safety threats. 

When I wrote the administration to dispute/amend Mr. S’s public safety flag, I was told that the public safety flags are an “objective documentation of a safety event” and not meant to be punitive. But there are many decisions and biases that enter into how an event is reported, be it in a public safety flag, in a patient history and physical, in a newspaper article, or in a textbook. Deciding what context to include or exclude is one factor that shapes the narrative. Moreover, the flag system may not be intended to be punitive, but the recommended actions (searches, patrols, and short-posts) have toxic effects on a person’s trust of the medical system and clinicians within it. A letter from a group of sickle cell clinicians at my institution documented several instances where Public Safety’s involvement triggered by the flag system led to humiliating and dehumanizing experiences for Black patients, including seemingly unwarranted physical searches and escorts. Mr. S is not a public safety threat and I will keep advocating for his flag to be removed.  

Public safety flags are commonplace across electronic medical systems in the United States. I fear that these flags can be weaponized in the way that a call to 911 in the outside world can be used to endanger a person of color. Are the public safety flags making the medical community – both staff and patients – safer? Or are they perpetuating systemic racism within a setting intended to care?

Alyse Wheelock, MD is a second year fellow in Infectious Diseases at Boston Medical Center. Her research interests are in Chagas disease and other tropical diseases affecting immigrants and refugees in the United States.