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. Our project focuses on vulnerable older patients over 65 who are diagnosed with fall or suspected urinary tract infection (UTI) in the ED (AHRQ priority population). 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). Our 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. In order for older adults to transition safely in their journey that begins in the ED, we propose to 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 use the SEIPS (Systems Engineering Initiative for Patient Safety) model as the conceptual framework for addressing multiple patient safety issues and healthcare-associated harm experienced by older adults during their care journey. We will apply a participatory human-centered design approach to implement the 5- step methodology described in the AHRQ RFA (problem analysis, design, development, implementation and evaluation). This will involve the creation of a multidisciplinary Intervention Implementation Team (IIT) with representatives from (1) patients/caregivers, (2) clinicians and staff from ED, hospital and SNF, (3) UW Health stakeholders, and (4) researchers. We will evaluate the impact of the patient safety passport on the most frequent and inter-related patient safety issues experienced by older adults in the domains of fall, VTE, diagnostic and medication errors, and HAIs. In line with the SEIPS model, the evaluation will assess care process and outcomes (EHR data), the perspective of patients and caregivers (survey and interviews), and the perspective of ED, hospital and SNF clinicians and staff (survey and focus groups). We will develop a transdisciplinary PSLL aimed at engineering safe care journeys for vulnerable patients, including older adults. Our PSLL will build on long-standing, strong research collaboration between engineering and the health sciences at the University of Wisconsin-Madison, which led to the official launch of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE) in 2017.

Public Health Relevance

Older adults over 65 are more likely to present to the emergency department and experience patient safety issues after the emergency department visit as compared to younger people. In this proposal, we will develop, design, implement and evaluate a patient safety passport that will support the safe journey of older adults diagnosed with a fall or suspected urinary tract infection in the emergency department. The innovative concept of patient safety passport will be used by patients, caregivers, and clinicians in the emergency department, hospital and skilled nursing facility, and will facilitate communication and coordination as the patient transitions from the emergency department and travels to the hospital, skilled nursing facility or home.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Special Emphasis Panel (ZHS1)
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Rodrick, David
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University of Wisconsin Madison
Engineering (All Types)
Biomed Engr/Col Engr/Engr Sta
United States
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