Significant racial and socioeconomic disparities in care quality and patient safety persist across and within countries. Recent evidence continues to show that a significant cause for the persistence of health disparities is grounded in systemic racism,1 that is, the way that the ideology of inferiority is embedded in health infrastructures, laws, policies and societal practices to perpetuate widespread unfair treatment of people of colour.2

These conditions undermine care quality and patient safety through the ways they are embedded in existing quality and safety infrastructure and their effects on patients and families. Compared with white patients, the electronic health records of black patients have 2.5 times the odds of having negative descriptors and stigmatising language (eg, ‘aggressive’) in their history and physical notes, which elicited less attention to patient concerns (eg, pain) and correspondingly less aggressive treatment.3 Voluntary safety reporting tends to understate the number and range of safety events experienced by black patients relative to automated systems (eg, the global trigger tool).4 Moreover, a recent report from the Urban Institute in the USA found that black patients had higher rates of adverse patient safety events on 6 of 11 measures and higher failure to rescue rates.5 The underlying conditions related to racism and structural inequities also impose a ‘cognitive tax’ on patients and families that has been shown to increase cognitive errors that impair ability to share symptoms and treatment adherence in ways that negatively affect care quality.6 To the extent these have received attention, it has been via specific quality improvement (QI) projects explicitly focused on inequities with specific (chronic) conditions such as diabetes.7 However, in only focusing on equity during specific ‘equity’ QI projects, QI teams miss opportunities to address how disparities and inequities embed in everyday care in ways that …