Health Literacy–Related Safety Events: A Qualitative Study of Health Literacy Failures in Patient Safety Events

INTRODUCTION: Communication failures are the leading root cause of safety events. Although much communication research focuses on the healthcare team, there is little focus on communication with patients and families. It is not known what deficits in health literate patient communication lead to patient safety events. We aimed to identify themes of health literacy–related safety events to describe the impact of health literate communication on patient safety. METHODS: The safety events were entered into a system-wide self-reported safety event collection database. A patient safety specialist trained in health literacy prospectively tagged events for health literacy. The authors retrospectively queried the database for all health literacy tagged events during 9 months (September 2017–May 2018). The authors reviewed and independently coded health literacy-associated safety events. Qualitative content analysis of events facilitated by software (NVivo) was completed to identify the health literacy–related safety event themes. RESULTS: Health literacy events comprised 4% (152/3911) of self-reported safety events during the 9 months. Main themes of the health literacy safety events related to (1) medication; (2) system processes; and (3) discharge/transition. Subthemes of each of the events further described the event types. Health literacy–associated safety events encompass all safety event outcomes (near miss, precursor, and serious safety events). CONCLUSIONS: Health literacy–related safety events occur in the healthcare environment. This review characterizing health literacy–related safety events prioritizes areas to implement health literate safety practices. Many opportunities exist to address communication-related safety events around medication, system processes, and discharge using health literate best practices.