Patient Safety Learning Lab (PSLL)

Overview: The combination of the aging population with increasingly complex care needs produces a major challenge for the healthcare delivery system. Older patients are at high risk for patient safety issues and healthcare-associated harm, especially when receiving care in the Emergency Department (ED) and the hospital. These patients experience a range of patient safety issues, such as repeated falls, diagnostic and medication errors (e.g. unnecessary use of antibiotics or drugs that increase fall risk), venous thromboembolism related to immobilization, and healthcare-associated infections (e.g., C-difficile). This project will create a ‘patient safety passport’ that will provide opportunities for error detection and recovery, for anticipating patient safety issues in the subsequent steps of the journey and for improving communication and coordination. We will evaluate the impact of the patient safety passport on patient safety issues. Building on strong research collaboration between engineering and the health sciences, we will develop a transdisciplinary Patient Safety Learning Laboratory (PSLL) aimed at engineering safe care journeys for vulnerable patients, including older adults.

Aims: The aims of the project are:

– to design, develop, implement and evaluate a system of care (identified as the patient safety passport) that supports the safe journey of older adults after ED presentation.

– to  develop a transdisciplinary Patient Safety Learning Laboratory (PSLL) aimed at engineering safe care journeys for vulnerable patients, including older adults. 

Funding: Agency for Healthcare Research and Quality (AHRQ)

Pascale Carayon, PhD
Multiple Principle Investigator
Procter & Gamble Bascom Professor in Total Quality
Department of Industrial and Systems Engineering
Director, Center for Quality and Productivity Improvement
University of Wisconsin-Madison

Maureen Smith, MD, MPH, PhD
Multiple Principle Investigator
Professor, Department of Population Health Sciences and Family Medicine, Community Health in School of Medicine & Public Health
University of Wisconsin-Madison

Roger Brown, PhD
Co-Investigator
Professor, School of Nursing
University of Wisconsin-Madison

Michelle Chui, PhD
Co-Investigator
Associate Professor, School of Pharmacy
University of Wisconsin-Madison

Barbara King, PhD
Co-Investigator
Associate Professor, School of Nursing
University of Wisconsin-Madison

Jingshan Li, PhD
Co-Investigator
Professor, Industrial and Systems Engineering
Associate Director of the Wisconsin Institute for Healthcare Systems Engineering
University of Wisconsin-Madison

Nasia Safdar, MD, PhD
Co-Investigator
Associate Professor, Department of Medicine
Associate Chief of Staff for Research at William S. Middleton Memorial VA Hospital
University of Wisconsin-Madison

Manish Shah, MD
Co-Investigator
Associate Professor, School of Medicine and Public Health
Vice-Chair of Research and Academic Affairs, Department of Emergency Medicine
University of Wisconsin-Madison

Nicole Werner, PhD
Co-Investigator
Assistant Professor, Industrial and Systems Engineering
University of Wisconsin-Madison

Azita Hamedani, MD, MPH, MBA
Physician Champion
Associate Professor, School of Medicine and Public Health
Chair, Department of Emergency Medicine
University of Wisconsin-Madison

Peter Hoonakker, PhD
Survey Scientist
Research Scientist, Associate Director of Research
Center for Quality and Productivity Improvement
University of Wisconsin-Madison

Brian Patterson, MD
Faculty, School of Medicine and Public Health
University of Wisconsin-Madison

Michael Pulia, MD, MS
Faculty, School of Medicine and Public Health
University of Wisconsin-Madison

Katie Ronk, BS
Lead Programmer

Allie DeLonay, BA
Programmer

Patrick Fergusson, MPH, CHES
Metric Development

Peter Nordby, MA
Research Specialist

Teresa Thuemling, BS
Administrator
Wisconsin Institute for Healthcare Systems Engineering
Center for Quality and Productivity Improvement
University of Wisconsin-Madison

Megan Salwei
Research Assistant
Center for Quality and Productivity Improvement
University of Wisconsin-Madison

Rachel Zenker
Research Assistant
Werner Lab
University of Wisconsin-Madison

Hanna Barton
Research Assistant
Werner Lab
University of Wisconsin-Madison

Kathryn Wust
Research Assistant
Center for Quality and Productivity Improvement
University of Wisconsin-Madison

2021

April 7, 2021: WIHSE AHRQ PSLL PhD Student Webinar

2020

Rutkowski, R., Salwei, M., Barton, H., Wurst, K., Hoonakker, P.L.T., Brenny-Fitzpatrick, M., King, B., Shah, M., Pulia, M., Patterson, B., Smith, M., Carayon, P., Werner, N.E.,(Accepted for presentation). Physicians perceptions of disposition decision-making for older adults in the Emergency Department: A Preliminary Analysis. Paper accepted for presentation at the HFES conference, Chicago, IL.

Salwei, M.E., Barton, H., Werner, N.E., Rutkowski, R., Hoonakker, P.L.T., Wust, K., Shah, M.N., Patterson, B.W., Pulia, M.S., Hamedani, A.G., Smith, M., King, B., Carayon, P. (Accepted). Identifying roles in older adults’ emergency transitions. Paper accepted for presentation at the HFES conference, Chicago, IL.