Although much attention has been paid to the reduction of disparities in health care within the United States, these issues continue to exist. Such efforts include increased focus on patient centeredness and cultural responsivity. These concepts are based on the recognition that diverse, marginalized, and vulnerable patients may possess different physical, psychologic, or social characteristics that contribute to their diversity and susceptibility. Such patients may face numerous obstacles and barriers when seeking medical care, including financial constraints, difficulties with communication, a limited understanding of how to navigate the health care system, and not feeling welcomed, respected, or safe. It is essential that the radiologist and members of the radiology care team understand and embrace patients' unique characteristics to provide effective and appropriate care to all patients. This article illustrates the spectrum of knowledge that benefits radiologists and members of the radiology care team when interacting with and providing care for the growing pool of diverse, marginalized, and vulnerable patients. © RSNA, 2018 • Abbreviations: LEP = limited English proficiency, LGBTQ = lesbian, gay, bisexual, transgender, or queer, PTSD = posttraumatic stress disorder

Purpose To investigate barriers to reporting safety concerns in an academic radiology department and to evaluate the role of human factors, including authority gradients, as potential barriers to safety concern reporting. Materials and Methods In this institutional review board-approved, HIPAA-compliant retrospective study, an online questionnaire link was emailed four times to all radiology department staff members (n = 648) at a tertiary care institution. Survey questions included frequency of speaking up about safety concerns, perceived barriers to speaking up, and the annual number of safety concerns that respondents were unsuccessful in reporting. Respondents' sex, role in the department, and length of employment were recorded. Statistical analysis was performed with the Fisher exact test. Results The survey was completed by 363 of the 648 employees (56%). Of those 363 employees, 182 (50%) reported always speaking up about safety concerns, 134 (37%) reported speaking up most of the time, 36 (10%) reported speaking up sometimes, seven (2%) reported rarely speaking up, and four (1%) reported never speaking up. Thus, 50% of employees spoke up about safety concerns less than 100% of the time. The most frequently reported barriers to speaking up included high reporting threshold (69%), reluctance to challenge someone in authority (67%), fear of disrespect (53%), and lack of listening (52%). Conclusion Of employees in a large academic radiology department, 50% do not attain 100% reporting of safety events. The most common human barriers to speaking up are high reporting threshold, reluctance to challenge authority, fear of disrespect, and lack of listening, which suggests that existing authority gradients interfere with full reporting of safety concerns.

In high-reliability industries that are dedicated to ensuring safety, safety event reporting is the cornerstone of improvement. However, human factors can interfere with consistent reporting. Common human factors that are barriers to safety event reporting include liability concerns; time constraints; physician autonomy; selfregulation; collegiality; the lack of listening, language training, and/ or feedback regarding reported events; unclear responsibilities within safety teams; and a high reporting threshold. Other barriers include fears of challenging authority, being disrespected, retribution, and the creation of a difficult work environment. These factors are reviewed in the health care setting, and the countermeasures that need to be introduced at the frontline employee, leadership employee (physicians and managers), and departmental and organizational levels to create a culture of safety in which all employees feel comfortable raising safety concerns are discussed. ©

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