Author: ALYSE WHEELOCK, MD, PGY-2
Public safety flags in medical records – the text, subtext, and repercussions
“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.
This is not a safe space: trust and inequities in the time of COVID-19
During a late-night shift in the Emergency Department (ED) in April, I took care of Mr. S, a man in his early twenties who presented with a sickle cell vaso-occlusive crisis. COVID-19 testing had returned negative. The carefully composed steps in his hematology care plan had begun to ease his pain. Yet his oxygen levels were hovering just below a safe level for discharge. In addition to further workup, he would need to stay the night, at least while requiring oxygen. Mr. S asked me to call his parents who could not visit him in the ED. They would not be pleased, he warned me; they wanted him home. After discussing the difficult balance of risks – those of staying in the hospital during the COVID surge or going home without oxygen – Mr. S and his parents ultimately agreed to him staying overnight. Even so, Mr. S’s father’s parting words were “if my son gets COVID in the hospital, it’s on you.” These words and the profound distrust they conveyed echoed in my head throughout the evening.
A few weeks later, on a late Friday afternoon during my telemedicine clinic, Mr. J was describing by phone what could have been a gout flare in his knee or, far more troubling, a case of septic arthritis. After staffing with my attending, I explained my concerns to Mr. J and recommended he go to the ED. I talked him through the new layout and triage process. Unlike Mr. S’s family, I knew Mr. J well – I had taken care of him in inpatient and outpatient settings since I was an intern. An elderly man from Puerto Rico, his experiences with gang-related violence decades ago had left him with PTSD, depression, and severe anxiety. When I told him I was graduating from residency, he said he wanted to give me one of his late mother’s rosaries. By Monday, he had not visited the ED and I reached back out. He said he simply could not overcome the fear of getting COVID-19. The red-hot pain, redness, and swelling in his knee had fortunately resolved over the weekend. For Mr. J, his distrust in the hospital’s ability to keep him safe superseded the trust we had each built over the course of three years.
Mr. S and Mr. J are both affected by multifold inequities in our health system, Mr. S as a Black man with sickle cell disease and Mr. J as a Latino man with mental health problems. They both come from neighborhoods that were hotspots for COVID-19 and had carefully avoided infection. Personal and institutional distrust affected the way they navigated non-COVID care within a pandemic-era hospital system and how they interacted with me, a white trainee. Concerns about infection likely shape every patient’s decision-making about visiting hospitals now. However, I fear that for people who have experienced medical bias or substandard care in the past, concerns about safety within the hospital space could pose devastating barriers to care. Learning about the mortality disparities in COVID-19 further validates distrust. Ongoing research has begun to examine decreases in standard care services provided during the pandemic [i],[ii]. A focus on inequities must inform this research. Interventions to address the findings must emphasize safety and trust in marginalized communities; for example, by providing more community-embedded services.
At every turn in the way the COVID-19 pandemic has played out, the American medical community has only retroactively recognized the inequities that compound each other to lead to Black and Brown people dying at much higher rates than their white counterparts. We must probe beyond the COVID-19 diagnosis to fully understand inequities in pandemic-era care.
Alyse Wheelock is a first-year fellow in Infectious Diseases at Boston Medical Center, where she also completed internal medicine residency.
[i] Garcia S, Albaghdadi MS, Meraj PM, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol 2020 April 9
[ii] Lange SJ, Ritchey MD, Goodman AB, et al. Potential Indirect Effects of the COVID-19 Pandemic on Use of Emergency Departments for Acute Life-Threatening Conditions — United States, January–May 2020. MMWR Morb Mortal Wkly Rep 2020;69:795–800. DOI: http://dx.doi.org/10.15585/mmwr.mm6925e2external icon