Overview of Patient Safety Learning Laboratory Projects

Patient safety learning laboratories (PSLLs) take a systems engineering approach to allow researchers and practitioners to evaluate clinical processes and enhance work and information flow to improve patient safety. The learning laboratories use cross-disciplinary teams to address the patient safety-related challenges providers face. This approach can involve evaluating the physical (built) environment, technological factors such as health information technology (IT), and clinical workflow processes relevant to the patient's condition. Emphasis is placed on the system-level confluence of these multiple factors in producing better patient safety.

AHRQ supports the PSLLs through the Agency's patient safety program. In 2014 and 2015, AHRQ funded 13 multiyear demonstration grants through the P30 mechanism to evaluate the use and effectiveness of various systems engineering approaches and the role they can play in improving the safety and quality of healthcare delivery.

In 2018, AHRQ funded nine additional PSLL grants through the R18 mechanism and expanded the focus to include projects that aim to improve diagnosis and treatment issues. This fact sheet briefly summarizes these projects. Each summary includes the project title, principal investigator and organization, AHRQ grant number, project start and end dates, and a description of the focus and goals of the project. Contact information for each principal investigator is at the end of the fact sheet.

AHRQ's PSLLs have the potential to improve the safety of healthcare by allowing healthcare practitioners to acquire valuable experience in a variety of clinical settings, reducing patient risk and improving safety. These newly funded projects will inform providers, health educators, payers, policymakers, patients, and the public about the effective use of systems engineering approaches in improving patient safety.

P30 Projects Funded in 2014 and 2015

Making Acute Care More Patient-Centered

Principal Investigator: David Bates, M.D., Brigham & Women's Hospital, Boston, MA
AHRQ Grant No.: HS23535
Project Period: 09/30/14 to 09/29/19
Description: The goal of this learning laboratory is to develop tools to engage patients, family, and professional care team members in reliable identification, assessment, and reduction of patient safety threats in real time, before they manifest in actual harm.

The project aims are to:

  1. Engage patients and their family caregivers in the design of health IT tools to prevent patient falls and related injuries during an acute hospitalization.
  2. Engage healthcare providers and patients in the design and development of a Patient Safety Checklist Tool to improve patient safety and quality outcomes, provider efficiency, and team communication.
  3. Iteratively develop and evaluate the impact of a patient safety reporting system on patient safety and foster a learning health system.

As a result of increasing implementation and use of health IT and patient/family engagement in their plan of care, this PSLL is providing information, strategies, and tools for using health IT to facilitate patient activation in eliminating harm in hospital settings.

Failure To Rescue Patient Safety Learning Lab

Principal Investigator: George Blike, M.D., Dartmouth-Hitchcock, Lebanon, NH
AHRQ Grant No.: HS24384
Project Period: 09/30/15 to 09/29/19
Description: The Failure to Rescue Patient Safety Learning Lab (FTR PSLL) is focused on creating the ideal hospital rescue system. Minimizing FTR (i.e., death following a major complication) is critical to reducing mortality in hospitalized patients. Successful rescue hinges on early recognition and timely management of serious complications once they occur.

The specific aims are to:

  1. Target gaps in understanding the technology factors behind ideal risk assessment and risk surveillance.
  2. Support early detection of complications and the human factors that support the ideal individual and team response in effectively managing these complications. .

A novel translation approach will be used to rapidly support reliable "early" rescue. Ultimately, the ideal integrated rescue system has potential to reduce both the mortality and harm currently associated with FTR.

Brain Health Patient Safety Learning Laboratory (Brain Safety Lab)

Principal Investigator: Christopher Callahan, M.D., Indiana University, Indianapolis, IN
AHRQ Grant No.: HS24384
Project Period: 09/30/15 to 09/29/19
Description: The Brain Safety Lab is a collaboration between the Indiana University School of Medicine, the Indiana University School of Informatics and Computing, the Indiana University School of Nursing, the Purdue University Schools of Biomedical and Industrial Engineering, the Purdue College of Pharmacy, the Regenstrief Institute, Inc., and a safety-net health care system (Eskenazi Health).

The specific aim of this project is to:

  1. Prevent harms to brain health among an AHRQ priority population at high risk for avoidable harm.

This learning lab focuses on patient safety harms related to the use of medications among older adults. It focuses on older adults because they are the largest reservoir of medication use, overuse, and misuse and are particularly vulnerable to brain safety concerns.

Yale Center for Healthcare Innovation, Redesign, and Learning

Principal Investigator: Sarwat Chaudhry, M.D., Yale University, New Haven, CT
AHRQ Grant No.: HS23554
Project Period: 09/30/14 to 09/29/19
Description: The goal of the Yale Center for Healthcare Innovation, Redesign, and Learning (CHIRAL) is to improve transitions of care. Patients being transferred from one setting to another or one clinical team to another are at increased risk for a host of failures, including identification errors, delayed or missed diagnoses, redundant testing, treatment delays or errors, medication errors, and unexpected clinical deterioration.

CHIRAL aims to:

  1. Improve patient safety at the time of transition through redesign of transfers of patients into Yale New Haven Hospital (YNHH) from outside hospitals and emergency departments (EDs).
  2. Redesign transfers within YNHH between the ED or intensive care unit and general hospital units.
  3. Redesign transfers out of YNHH to the community.

All projects examine transitions through similar conceptual lenses of shared sense making (a collective ability to make sense of complicated, dynamic, and ambiguous information without oversimplifying or ignoring discordant data) and latent systems conditions (considering the influence of workflow, skills, culture, staffing patterns, equipment, incentives, and information technology). These projects take a similar design and engineering approach to clinical redesign, beginning with indepth problem analysis, and then proceeding through design (brainstorming), development (prototyping), implementation, and evaluation phases.

Optimizing Safety of Mother and Neonate in a Mixed Methods Learning Laboratory

Principal Investigator: Louis Halamek, M.D., Stanford University, Stanford, CA
AHRQ Grant No.: HS023506
Project Period: 09/30/14 to 09/29/19
Description: The overall goal of this project is to establish a PSLL to advance patient safety for neonates and mothers before, during, and after delivery.

The laboratory is carrying out four interrelated projects to:

  1. Develop and test an optimal neonatal resuscitation data display,
  2. Develop and test an optimal maternal data display,
  3. Develop a process to recognize and prevent maternal clinical deterioration, and
  4. Develop the optimal physical design of a labor and delivery suite.

Three specific aims guide this project:

  1. The researchers are studying how flow of communication may affect patient safety. In this context, the flow of communication usually refers to the passing of information (in either direction) between clinicians others, primarily other clinicians.
  2. The study seeks to examine how physical design elements may affect patient safety. Design elements may range from design of physical devices and organization of patient beds and storage spaces to layout of a patient room.
  3. The project seeks to develop a systematic approach to studying patient safety using a stepwise approach of problem analysis through qualitative research, design, development, implementation, and evaluation.

This project expands the knowledge base on patient safety for neonatal and maternal care by bringing together obstetrics, neonatology, nursing, design specialists, engineers, and parent representatives, and by using simulation methodology to develop, pilot, and test innovative designs.

Patient Imaging Quality and Safety Laboratory

Principal Investigator: Leora Horwitz, M.D., New York University, New York, NY
AHRQ Grant No.: HS24376
Project Period: 09/30/15 to 09/29/19
Description: The goal of the New York University (NYU) Patient Imaging Quality and Safety Laboratory (PIQS Lab) is to be a dynamic learning environment focused on improving safety and outcomes for patients. The multidisciplinary PIQS Lab will connect experienced clinicians in the NYU Departments of Radiology, Emergency Medicine, Medicine, Orthopedics, Surgery, and Urology with operations, human factors, and management experts at NYU Langone Medical Center (NYULMC), NYU Wagner School of Public Policy, and NYU Stern School of Business; and with design experts at design firm IDEO.

The aims of this learning lab are to:

  1. Redesign the radiology ordering process in the outpatient setting to minimize inappropriate or unnecessary radiology tests.
  2. Redesign the inpatient consultation process to improve patient safety.
  3. Enhance the followup of radiology test results to improve patient outcomes.

All projects examine radiology imaging failures through similar conceptual lenses of shared sense making (making sense of dynamic and ambiguous information without oversimplifying or ignoring discordant data) and sociotechnical systems (nature of the work, human-system interfaces, organization, environment, management). PIQS Lab faculty take a design and engineering approach to clinical redesign, beginning with indepth problem analysis, then proceeding through design (brainstorming), development (prototyping), implementation, and evaluation phases.

Realizing Improved Patient Care Through Human-Centered Design in the Operating Room

Principal Investigator: Anjali Joseph, Ph.D., Clemson University, Clemson, SC
AHRQ Grant No.: HS24380
Project Period: 09/30/15 to 09/29/19
Description: The overarching goal of the "Realizing Improved Patient Care Through Human-Centered Design in the Operating Room" (RIPCHD.OR) Learning Lab is to develop an evidence-based framework and methodology for the design and operation of a general surgical operating room to improve safety.

The specific aims are to:

  1. Improvethe usability of anesthesia-related alarms in the OR.
  2. Understand and improve traffic flow in the OR.
  3. Incorporate modern technology into OR designs.

RIPCHD.OR uses a multidisciplinary human-centered approach that incorporates evidence-based design, human factors, and systems engineering principles. The design, process, and technology solutions that emerge from this learning lab will be implemented and tested in the new Medical University of South Carolina Ambulatory Surgery Center in Charleston, SC.

Institute for the Design of Environments Aligned for Patient Safety

Principal Investigator: Susan Moffatt-Bruce, M.D., Ohio State University, Columbus, OH
AHRQ Grant No.: HS24379
Project Period: 09/30/15 to 09/29/19
Description: The goal of the Institute for the Design of Environments Aligned for Patient Safety (IDEA4PS) is to improve workflows and information transfers in the healthcare environment.

The learning lab aims to:

  1. Explore how cardiac alarms affect healthcare provider decision making.
  2. Conduct surveillance of healthcare-acquired infections in real time.
  3. Implement and evaluate secure messaging in electronic health records.

This learning lab integrates system engineering, design, human factors, organizational behavior, evaluation, and data analysis to explore the way feedback of information is incorporated into the adaptation of work systems to enhance patient safety. The intent is to frame how all kinds of data, both those currently collected and newly acquired, are leveraged to actionable information and linked to patient outcomes.

Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab)

Principal Investigator: Sanjay Saint, M.D., University of Michigan, Ann Arbor, MI
AHRQ Grant No.: HS24385
Project Period: 09/30/15 to 09/29/19
Description:  The goal of this learning lab is to increase communication and cognition among healthcare workers to improve the safety of hospitalized patients. To achieve this goal, the learning lab is developing two projects to:

  1. Develop an alert system to reduce pressure ulcers in hospitalized patients; and
  2. Target cognitive processes that contribute to errors in diagnosis and treatment. 

The specific aim is to:

  1. Establish a cohesive M-Safety Lab composed of multidisciplinary, collaborating teams of investigators supported by a robust infrastructure, including an Innovation, Development, Evaluation, and Administration (IDEA) Core that will help oversee the development and successful completion of both projects from problem analysis to evaluation and will provide methodological, technical, and administrative support to the M-Safety Lab.

The M-Safety Lab focuses on developing and then testing novel approaches—through the use of healthcare engineering—to enhance medical decision making through cognition and communication to reduce hospital-acquired complications. The learning lab's work is significant, because the projects integrate relevant disciplines to improve patient safety and could be scaled up if evidence suggests these approaches are effective.

Transdisciplinary Learning Lab to Eliminate Patient Harm and Reduce Waste

Principal Investigator: Adam Sapirstein, M.D., Johns Hopkins University, Baltimore, MD
AHRQ Grant No.: HS23553
Project Period: 09/30/14 to 03/29/19
Description: The goal of the Johns Hopkins Armstrong Institute Learning Lab is to use systems engineering methods to partner with patients, patients' families, and others to eliminate preventable harm, optimize patient outcomes and experience, and reduce waste in healthcare.

Their aims are to:

  1. Develop high-level design requirements for an ideal intensive care unit, using design thinking and system engineering methods.
  2. Leverage open-application programming interfaces to engineer interoperability between electronic health records and infusion pumps.
  3. Develop and implement an indicator of unit-level stress in an engineered care system to predict and mitigate risk.

The learning lab's program plan incorporates design thinking and systems engineering, using a model the Johns Hopkins University's Applied Physics Lab team developed for the U.S. Navy's submarine force. This provides healthcare with a model for systematically envisioning and iterating a broad system objective and the necessary component activities required to realize that objective.

Building an Ambulatory Patient Safety Learning Laboratory for Diverse Populations (ASCENT)

Principal Investigator: Urmimala Sarkar, M.D., University of California-San Francisco, San Francisco, CA
AHRQ Grant No.: HS023558
Project Period: 09/30/14 to 09/29/19
Description: The overall goal of this project is to examine the epidemiology of patient safety in ambulatory care settings that care for diverse, low-income populations.

The aims are to:

  1. Develop feasible, timely, and accurate electronic measures of patient safety notification and monitoring gaps in an ambulatory care setting for high-risk subpopulations and characterize the extent of disparities in patient safety.
  2. Conduct a root cause analysis of patient safety notification/monitoring gaps in five public ambulatory care settings to identify factors contributing to these disparities.
  3. Evaluate the pilot implementation of patient safety monitoring methodologies developed from Aims 1 and 2 across five diverse ambulatory healthcare settings.

The design and development components of this project address issues such as: (a) test results management; (b) outpatient monitoring for high-risk conditions; and (c) enhanced medication comprehension to reduce adverse drug events. The approach emphasizes implementation sciences methodology with a quasi-experimental design to assess outcomes. .

Engineering Highly Reliable Learning Lab

Principal Investigator: Sara Singer, Ph.D., Harvard University, Cambridge, MA
AHRQ Grant No.: HS24453
Project Period: 09/30/15 to 09/29/19
Description: The goal of this learning lab is to enhance capacity for innovation and develop highly reliable systems that address communication and coordination challenges that pose patient safety risks at the intersection of primary and specialty care. A five-stage innovation cycle, including problem analysis, design, development, implementation, and evaluation, drives learning lab efforts to develop highly reliable systems within 19 Harvard-affiliated primary care practices and their specialty care partners.

The specific aims are to:

  1. Transform a highly functioning collaborative into a primary care learning laboratory (PCLL) to increase capacity for innovation and to address key patient safety challenges in primary care settings.
  2. Apply systems engineering and operations management theory and methodologies to design and develop innovative solutions for improving safety for patients at risk for cancer and for patients at risk for a variety of harms due to complex medical and/or psychosocial circumstances.
  3. Implement and evaluate redesigned systems across PCLL practices.
  4. Assess the impact of the PCLL on practice, team, provider, and patient outcomes.

Three synergistic projects engage health system-based reengineering and design teams in problem analysis and hands-on development, testing, and implementation of highly reliable closed-loop systems for high-priority primary to specialty care referrals; coordination systems for children with medical complexity undergoing surgery; and diagnosis and management systems for new medical conditions in adults with complex care needs.

Caregiver Innovations to Reduce Harm in Neonatal Intensive Care

Principal Investigator: Eric J. Thomas, M.D., University of Texas, Houston, TX
AHRQ Grant No.: HS24459
Project Period: 09/30/15 to 09/29/19
Description: The goal of the University of Texas Patient Safety Learning Laboratory is to create an environment of collaborative learning focused on reducing all-cause preventable harm by 50 percent in the neonatal intensive care unit (NICU).

The specific aims are to:

  1. Increase parent engagement.
  2. Improve staff training on nutrition and respiratory care in neonates.

The learning lab will achieve its goals and aims by using five cores of experts in robust process improvement (methods of Lean, Six Sigma, and change management); electronic health records; parent engagement; patient safety measurement; and project administration and leadership. These experts will collaborate with clinician leaders, frontline caregivers, and parents from Memorial Hermann Health System NICUs to reduce all preventable harms.

R18 Projects Funded in 2018

Improving the Safety of Diagnosis and Therapy in the Inpatient Setting

Principal Investigator: David Bates, M.D., Brigham & Women’s Hospital, Boston, MA
AHRQ Grant No.: HS26613
Project Period: 09/01/18 to 06/30/21
Description: This learning lab will focus on improving diagnosis and linking that diagnosis to the correct treatment in acute care. To address this overall issue, the lab will use rigorous systems engineering and human factors methods to guide its approach as shown in the specific aims for the project:

  1. Problem Analysis – Use systems engineering methods to analyze the problem of diagnostic and therapeutic error and identify system and cognitive factors for a set of morbid, costly common conditions and undifferentiated symptoms.
  2. Design and Development – Use human factors methods and rapid, iterative prototyping to design and develop potential solutions and develop a set of interventions to engage the care team and patient/caregivers to ensure treatment trajectories match the anticipated course for working diagnoses or symptoms, ensuring alignment with patient and clinician expectations.
  3. Implementation and Evaluation – Pilot test, train clinical staff, and implement the intervention in the acute care setting, assess impact on diagnostic errors that lead to patient harm (stepped wedge), and perform quantitative and qualitative evaluations.

From the current PSLL and other work, lab investigators have built a variety of technological approaches they can use to interact with patients and providers. For example, they will use a safety dashboard, integrated with the health system's electronic health record, which is routinely used as a checklist to ensure safety during delivery of care at Brigham & Women’s Hospital. The lab will also ask patients (and their caregivers as appropriate) whether they are concerned that their diagnosis or treatment may not be correct and will share that concern with the care team.

Pediatric Patient Safety Learning Laboratory to Reengineer Continuous Physiologic Monitoring Systems

Principal Investigator: Christopher Bonafide, M.D., M.S.C.E., Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA
AHRQ Grant No.: HS26620
Project Period: 09/30/18 to 07/31/22
Description: The PSLL at CHOP has the goal of analyzing and reengineering hospital and home physiologic monitoring systems to maximize alarm informativeness; reduce alarm fatigue; and improve critical illness detection, diagnosis, and treatment. The lab will assess current monitoring systems used to continuously monitor children’s vital signs in hospital ward and home settings. The lab will evaluate the alarms intended to warn caregivers and nurses in the hospital and parents at home of conditions that warrant their immediate attention.

The project’s specific aims are to:

  1. Reengineer the system of monitoring hospitalized children on acute care wards, with a focus on reducing noninformative alarms and accelerating nurse responses to critical events.
  2. Reengineer the system of monitoring infants with bronchopulmonary dysplasia at home, with a focus on reducing noninformative hypoxemia alarms and improving clinicians’ access to usable longitudinal pulse oximetry data to inform supplemental oxygen treatment.

This PSLL brings together expertise from CHOP, University of Pennsylvania, and the ECRI Institute in diverse areas, including patient safety, pediatric hospital medicine, neonatology, nursing, systems engineering, human factors, design, medical device development, electronic health record clinical decision support, cognitive informatics, simulation, and biostatistics. This project will use a framework based on the Systems Engineering Initiative for Patient Safety model and Dual Process Theory and will apply innovative methods such as forensic accident investigation, video alarm analysis, and in situ simulation to analyze and evaluate monitoring systems.

Engineering Safe Care Journeys for Vulnerable Older Adults

Principal Investigator: Pascale Carayon, Ph.D., University of Wisconsin (UW), Madison, WI
AHRQ Grant No.: HS26624
Project Period: 09/30/18 to 07/31/22
Description: This learning lab will develop a transdisciplinary project focusing on care for vulnerable older patients over 65 who are diagnosed with a fall or a suspected urinary tract infection in the ED. In order for older adults to transition safely in their journey that begins in the ED, researchers propose creating 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.

Researchers will use the Systems Engineering Initiative for Patient Safety model as the conceptual framework for addressing multiple patient safety issues and healthcare-associated harms experienced by older adults during their care journey. The lab’s transdisciplinary team of engineers, health services researchers, nurses, physicians, and pharmacists will collaborate with UW Health, a large health system with both academic and community EDs, to create and evaluate a system of care that supports the safe journey of older adults after presentation to the ED.

The learning lab has the following specific aims:

  1. Using a systematic analysis, 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.
  2. Develop a transdisciplinary PSLL aimed at engineering safe care journeys for vulnerable patients, including older adults.

Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery

Principal Investigator: Ken Catchpole, Ph.D., Medical University of South Carolina, Charleston, SC
AHRQ Grant No.: HS26625
Project Period: 09/30/18 to 07/30/22
Description: This learning lab will conduct a study of anesthesia medication safety systems. The lab will use a multidisciplinary team of anesthesiologists, human factors professionals, biomedical engineers, pharmacists, and certified registered nurse anesthesiologists to engineer reductions in anesthesia medication errors in operating rooms in order to address three sources of failure: preparation and delivery errors (Failures of Execution); decision making involved in diagnosing and prescribing (Failures of Intention); and the complexity of the working environment, the physical workspace, or safety culture (Performance Shaping Factors).

The learning lab has the following specific aims:

  1. Explore solutions to failures in diagnosis, selection, and prescribing of intraoperative anesthesia medication.
  2. Develop methods to reduce failures in the preparation, administration, and recording of intraoperative anesthesia medication.
  3. Understand and improve workspace design and safety culture to influence anesthesia medication selection and delivery.

Connected Emergency Care Patient Safety Learning Lab

Principal Investigator: Scott Levin, M.S., Ph.D., Johns Hopkins University, Baltimore, MD
AHRQ Grant No.: HS26640
Project Period: 09/30/18 to 07/31/22
Description: The objective of the Connected Emergency Care Patient Safety Learning Lab is to reduce health and financial harm for patients with lower respiratory tract infection (LRTI) caused by a fragmented emergency care system. Using advanced data science methods and electronic health record-integrated clinical decision support (CDS), researchers will establish a connected (closed-loop) emergency care system through which the following specific aims are achieved:

  1. Optimize diagnostic performance for patients with suspected LRTI by: (a) minimizing overuse of avoidable imaging and laboratory testing; and (b) expediting detection of patients with severe LRTI.
  2. Increase the specificity of antibiotic treatment for patients with LRTI by: (a) reducing inappropriate prescribing; and (b) enabling targeted antibiotic therapy, indication, spectrum, and dose.
  3. Improve transition of care outcomes after the ED encounter is complete by reducing: (a) unnecessary hospitalizations and sudden care-level changes for those admitted; and (b) 30-day postencounter acute care utilization for those discharged.

The lab will use a systems engineering approach to CDS development that connects ED clinicians to the patient’s pre-encounter context, postencounter outcomes, and intraencounter current and projected state. The lab will accomplish this by increasing the use of longitudinal, contextual assessments considering the time pressure and excessive cognitive loading in the ED.

Improving Diagnosis in Emergency and Acute Care: A Learning Laboratory

Principal Investigator: Prashant Mahajan, M.D., M.P.H., M.B.A., University of Michigan, Ann Arbor, MI
AHRQ Grant No.: HS26622
Project Period: 09/30/18 to 07/31/22
Description: The Improving Diagnosis in Emergency and Acute Care Learning Laboratory (IDEA-LL) will address diagnostic decision making, associated cognitive processes, and uncertainty in EDs. To reduce diagnostic errors in the ED, researchers will use methods that illustrate the dynamics of human-system interaction during diagnostic processes. The lab’s goal is to create a program for diagnostic safety surveillance and intervention using actionable, patient-centered data obtained from both frontlines of care and electronic health records.

The lab has the following specific aims:

  1. Follow an iterative process to understand the detailed process of diagnostic decision making and identify potential factors that lead to diagnostic errors, using mixed methods-grounded theory (i.e., combining qualitative data [participant observations, indepth participant interviews] and mining of historical data).
  2. Develop a comprehensive list of patient, provider/care team, and system-level contributory factors and identify interventions to be studied using consensus methods.
  3. Test the effectiveness and impact of the interventions at the four EDs using mixed methods (i.e., quantitative and qualitative measures).

IDEA-LL will use multidisciplinary approaches to design, implement, and evaluate interventions to improve diagnostic safety. The investigative team, led by a unique physician-engineer partnership, will form a transdisciplinary environment of clinicians, nurses, patients, engineers, informaticians, and designers as an integral aspect of the learning laboratory to address both pediatric and adult emergency care in academic and community EDs.

Acute Care Learning Laboratory – Reducing Threats to Diagnostic Fidelity in Critical Illness

Principal Investigator: Brian Pickering, M.B., B.CH., Mayo Clinic, Rochester, Rochester, MN
AHRQ Grant No.: HS26609
Project Period: 09/30/18 to 07/31/22
Description: This learning lab will use mixed-methods and systems engineering research approaches to understand the interplay of the multiple factors contributing to diagnostic error and delay. The lab’s work will address ineffective implementation of diagnostic improvement strategies that focused on the healthcare team’s role but failed to incorporate the complexity of the organizational and systems processes within the clinical environment. The “Control Tower” system will be the staging ground for the in situ learning laboratory and will be built on top of a well-established clinical informatics infrastructure and hospital environment open to innovation and practice change.

The learning lab has the following specific aims:

  1. Develop and validate automated phenotypes of diagnostic error and delay that can be applied in near-real time to medical record data.
  2. Engage stakeholders in the mixed-methods and systems engineering approach to identify factors contributing to diagnostic error and delay. Then design and develop applicable system-based interventions.
  3. Evaluate the feasibility and preliminary effectiveness of learning laboratory interventions on the rate of diagnostic error and delay in patients with emerging critical illness.

Ambulatory Pediatric Safety Learning Lab

Principal Investigator: Kathleen Elizabeth Walsh, M.D., M.Sc., Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
AHRQ Grant No.: HS26644
Project Period: 09/30/18 to 09/29/22
Description: The Ambulatory Pediatric Safety Learning Lab is focusing on preventable harm in children caused by healthcare, focusing specifically on management of chronic conditions with families. The overarching goal is to redesign systems of care and coordination between the clinic and home to eliminate harm due to healthcare in these settings.

The learning lab aims to:

  1. Redesign processes for adjustment of medication dosing based on clinical information gathered by the patient/family to prevent medication errors. (This approach will be studied in type 1 diabetes.)
  2. Create processes for patient/family medication monitoring and communication with the clinic to prevent adverse drug events. (This approach will be studied in children with autism spectrum disorder on antipsychotics.)
  3. Design a workflow to plan for, detect, and prompt management of serious illness among children with chronic conditions at home. (This approach will be studied in both populations.)

This learning lab draws on design expertise from the Mad*Pow design agency, systems engineering expertise from the University of Wisconsin Systems Engineering Initiative, and patient-centered research and implementation expertise from the Cincinnati Children’s Hospital. Upon completion of the project, lab researchers plan to scale the interventions nationally through the Solutions for Patient Safety (SPS) Network and improve pediatric ambulatory safety across the United States.

Cancer Patient Safety Learning Laboratory (CaPSLL): Preventing Clinical Deterioration in Outpatients

Principal Investigator: Matthew Weinger, M.D., Vanderbilt University Medical Center, Nashville, TN
AHRQ Grant No.: HS26616
Project Period: 09/30/18 to 09/29/22
Description: The Cancer Patient Safety Learning Laboratory addresses the problem of effective clinical surveillance, early recognition, timely notification of the appropriate clinician, and effective intervention to prevent and mitigate clinical deterioration in medically complex (e.g., cancer) patients. To address the specific safety issues in failure to rescue, hospitals have introduced new tools and processes (e.g., continuous monitoring, early warning systems, rapid response teams).

The specific aims of the lab are to:

  1. Create and refine software tools and a predictive model for a surveillance-and-response system to prevent harm from unexpected all-cause clinical deterioration in outpatients receiving cancer treatment.
  2. Create and refine processes and training that engage patients and their caregivers as active and reliable participants in detecting and reporting potential clinical deterioration. Researchers will apply high reliability organizational principles and theories to develop processes and training for the relevant team, the cancer patients, their caregivers, and the clinicians who need to respond to signals from the surveillance system.
  3. Implement in the operational environment and formally evaluate the integrated detection and response tools and processes.

CaPSLL is a collaboration between the Vanderbilt-Ingram Cancer Center, human factors and systems engineering faculty in the Center for Research and Innovation in Systems Safety, and faculty in the Schools of Engineering and Management. The lab will partner with surgeons, oncologists, nurses, staff, adult patients with lung and head or neck cancer recovering from or undergoing treatment as outpatients, and their lay caregivers to more reliably detect and respond more effectively to unexpected clinical deterioration.

Contact Information

PI Name Email Address Phone Number Institution AHRQ Project Officer
Bates, David dbates@partners.org (301) 664-8767 Brigham and Women’s Hospital Rodrick, David
Chaudhry, Sarwat sarwat.chaudhry@yale.edu (203) 458-0604 Yale University Burgess, Denise
Halamek, Louis halamek@stanford.edu (650) 724-4444 Stanford University Chew, Emily
Sapirstein, Adam asapirs1@jhmi.edu (410) 502-3233 Johns Hopkins University Rodrick, David
Sarkar, Urmimala usarkar@medsfgh.ucsf.edu
(415) 206-4273 University of California-San Francisco Shofer, Margie
Blike, George george.t.blike@hitchcock.org (603) 653-9733 Dartmouth-Hitchcock Burgess, Denise
Callahan, Christopher ccallaha@iupui.edu
(317) 423-5600 Indiana University Rodrick, David
Horwitz, Leora leora.horwitz@nyumc.org (646) 501-2848 New York University Rodrick, David
Joseph, Anjali anjalij@clemson.edu (864) 656-2273
(404) 583-5760
Clemson University Rodrick, David
Moffatt-Bruce, Susan susan.moffatt-bruce@osumc.edu (614) 293-4509 Ohio State University Gray, Darryl
Saint, Sanjay saint@umich.edu (734) 615-8341 University of Michigan Rodrick, David
Singer, Sara ssinger@hsph.harvard.edu (617) 432-7139 Harvard University Rodrick, David
Thomas, Eric eric.thomas@uth.tmc.edu (713) 500-7958 University of Texas Burgess, Denise
Bonafide, Christopher bonafide@email.chop.edu   Children’s Hospital of Philadelphia Rodrick, David
Carayon, Pascale pcarayon@wisc.edu (608) 265-0503 University of Wisconsin Madison Rodrick, David
Catchpole, Ken catchpol@musc.edu (843) 792-4955 Medical University of South Carolina Rodrick, David
Levin, Scott slevin33@jhmi.edu   Johns Hopkins University Rodrick, David
Mahajan, Prashant pmahajan@med.umich.edu (734) 763-9849 University of Michigan-Ann Arbor Rodrick, David
Pickering, Brian pickering.brian@mayo.edu   Mayo Clinic, Rochester Burgess, Denise
Walsh, Kathleen Elizabeth kathleen.walsh@cchmc.org (513) 803-4588 Cincinnati Children’s Hospital Medical Center Perfetto, Deborah
Weinger, Matthew matt.weinger@vanderbilt.edu (615) 936-6598 Vanderbilt University Medical Center Rodrick, David

AHRQ Project Officer Email Addresses

For more specific information on AHRQ's research priorities and funding opportunities, please visit Funding and Grants.

For specific programmatic questions about Patient Safety Learning Laboratories and other patient safety topics, please contact:

David Rodrick, Ph.D.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Phone: 301-427-1876
Email: David.Rodrick@ahrq.hhs.gov

Page last reviewed August 2019
Page originally created December 2016
Internet Citation: Overview of Patient Safety Learning Laboratory Projects. Content last reviewed August 2019. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/resources/learning-lab/index.html
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