Trans and Gender-Diverse Patient Safety: Accurate Identification and Use of Sex Assigned at Birth and Gender Identity Information

A ccurate identification and use of sex assigned at birth (SAAB) and gender identity information are imperative for trans and gender-diverse (TGD) patient safety.Previous studies and literature reveal that miscommunication and/or misidentification of either SAAB or gender identity do occur, 1-4 and this creates risk of patient harm and erroneous care. 3,5 PA-PSRS Reports of Events Involving TGD PatientsWe reviewed a sample of event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in which the patients involved were TGD and the event was described as involving inaccurate identification of or inattention to SAAB and/or gender identity information.The following are vignettes from a sample of the event reports:A 24-year-old transgender male was prepped for elective head and neck surgery.The surgeon's office was aware that the patient was a female at birth; however, this information was not conveyed through the scheduling document that was sent to the clinic.Furthermore, during the preoperative phone call and on the day of the procedure, the patient repeatedly stated that they were a male at birth.Shortly before taking the patient to the operating room, a staff member recognized the patient from a surgery at a different facility.This prompted further questioning of the patient, who then confirmed that their SAAB was actually female.Due to the patient's age and reproductive potential, the staff requested permission to administer a pregnancy test prior to anesthesia.