Improving Patient Safety Through Learning Laboratories


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 involve 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 Announcement "Patient Safety Learning Laboratories: Innovative Design and Development to Improve Healthcare DeliverySystems" (P30). The P30 grants were funded to evaluate the use and effectiveness of various systems engineering approaches and the role they can play in improving the safety and quality of health care delivery.

AHRQ's PSLLs have the potential to improve the safety of health care by allowing health care practitioners to acquire valuable experience in a variety of clinical settings so they can reduce patient risk and improve 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.

Project Descriptions

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 09/29/18
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 health care 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 (FTR)-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: This lab establishes a Failure To Rescue (FTR) Patient Safety Learning Lab that 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

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 goal of this learning lab is to establish the Brain Health Patient Safety Learning Laboratory ("Brain Safety Lab") at the Indiana University School of Medicine in collaboration with 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 establish a patient safety learning laboratory focused on preventing harms to brain health among an AHRQ priority population at high risk for avoidable harm.

Within this broader aim, two distinct projects are being carried out that aim to address two interrelated threats to brain safety:

  1. Reducing the use of unsafe medications with anticholinergic side effects.
  2. Preventing repeated episodes of hypoglycemia among older adults with diabetes.

This learning lab focuses on patient safety harms related to the use of medications among older adults. The learning lab 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 09/29/18
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 their hospital from outside hospitals and emergency departments (EDs).
  2. Redesign transfers within their hospital between the ED or intensive care unit (ICU) and general hospital units.
  3. Redesign transfers out of their hospital to the community (skilled nursing facilities).

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 09/29/18
Description: The overall goal of this project is to establish a Patient Safety Learning Laboratory 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 information being given to and received by clinicians to others, primarily to 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 in their projects.

Patient Imaging Quality and Safety Laboratory (PIQS Lab)

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 OR

Principal Investigator: Anjali Joseph, Ph.D., Clemson University, Clemson, SC
AHRQ Grant No: HS24380
Project Period: 09/30/15 - 09/29/19
Description: The overarching goal of the "Realizing Improved Patient Care Through Human-Centered Design in the OR" (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 of this lab are to:

  1. Improve anesthesia-related care and safety in the OR by examining workstation design.
  2. Understand and improve traffic flow in the OR, such as placement of equipment.
  3. Incorporate modern technology into OR designs, by looking at OR design as a complete system..

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.

The 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 - 09/29/19
Description: The goal of the Institute for the Design of Environments Aligned for Patient Safety (IDEA4PS) is to develop an institute to improve workflows and information transfers in the health care environment.

The learning lab aims to:

  1. Explore how cardiac alarms affect health care provider decision making..
  2. Conduct surveillance of health care-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.

Transdisciplinary Learning Lab to Eliminate Patient Harm and Reduce Waste

Principal Investigator: Peter Pronovost, M.D., Johns Hopkins University, Baltimore, MD
AHRQ Grant No: HS23553
Project Period: 09/30/14 - 09/29/18
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 health care.

Their aims are to:

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

Their 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 health care with a model for systematically envisioning and iterating a broad system objective and the necessary component activities required to realize that objective.

Enhancing Patient Safety Through Cognition and Communication

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 health care workers to reduce hospital-acquired conditions. The M-Safety Lab comprises 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 two projects from problem analysis to evaluation.

The project's specific aims are to:

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

The M-Safety Lab focuses on developing and then testing novel approaches—through the use of health care 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.

Building an Ambulatory Patient Safety Learning Laboratory for Diverse Populations

Principal Investigator: Urmimala Sarkar, M.D., University of California-San Francisco, San Francisco, CA
AHRQ Grant No: HS023558
Project Period: 09/30/14 - 09/29/18
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 health care 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 of the synergistic projects focus on critical junctures with primary care: primary care referrals to specialty care; primary care and surgical teams for children with complex medical needs; primary care and others involved in pain management with opioids; and primary care and hospitalists and home health for 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 - 09/29/19
Description: The goal of the University of Texas at Houston (UTH) Patient Safety Learning Laboratory (UTPSLL) is to create an environment of collaborative learning focused on reducing all-cause preventable harm by 50% 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 (e.g., physicians, nurses, respiratory therapists) 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.

More Information

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:

Kerm Henriksen, Ph.D.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Phone: 301-427-1331


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


Page last reviewed December 2017
Page originally created December 2016
Internet Citation: Improving Patient Safety Through Learning Laboratories. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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