AHRQ Patient Safety Learning Labs Help Identify Barriers to Making Care Safer

A recent article by AHRQ researchers in the Journal of Patient Safetydescribes the challenges and obstacles confronted by AHRQ-funded Patient Safety Learning Laboratories (PSLLs). The 22 PSLLs are multidisciplinary teams that use design thinking and systems engineering principles to understand safety challenges and improve healthcare delivery systems. Each PSLL employs a five-phase methodology—problem analysis, design, development, implementation and evaluation—as the foundation for its four-year project. Though most of the PSLL work is in progress, the article’s authors suggested the impact of the initiative can be described in three ways: sharing results and lessons learned with the scientific community; enhancing care delivery to some degree at the system or unit level; and spurring the beginning of culture change for institutions to address problems. Access the abstract, and learn more about new PSLL projects aimed at supporting AHRQ’s growing emphasis on promoting diagnostic safety.

2019 Feb 9. doi: 10.1097/PTS.0000000000000577. [Epub ahead of print]

Pursuing Patient Safety at the Intersection of Design, Systems Engineering, and Health Care Delivery Research: An Ongoing Assessment.

Henriksen K1, Rodrick D, Grace EN, Shofer M, Jeffrey Brady P.

Author information

Abstract

OBJECTIVES:

Despite endorsements for greater use of systems approaches and reports from national consensus bodies calling for closer engineering/health care partnerships to improve care delivery, there has been a scarcity of effort of actually engaging the design and engineering disciplines in patient safety projects. The article describes a grant initiative undertaken by the Agency for of Healthcare Research and Quality that brings these disciplines together to test new ideas that could make health care safer.

METHODS:

Collectively known as patient safety learning laboratories, grantee teams engage in phase-based activities that parallel a systems engineering process-problem analysis, design, development, implementation, and evaluation-to gain an in-depth understanding of related patient safety problems, generate fresh ideas and rapid prototypes, develop the prototypes, ensure that developed components are implemented as an integrated working system, and evaluate the system in a simulated or clinical setting.

FINDINGS:

Obstacles are described that can derail the best of intentions in deploying the systems engineering methodology. Based on feedback received from project teams, lessons learned are emerging that find considerable variation among project teams in deploying the methodology and a longer than anticipated amount of time in bringing team members from different disciplines together where they learn to communicate and function as a team.

CONCLUSIONS:

Three narratives are generated in terms of what success might look like. Much is yet to be learned about the limitations and successes of the ongoing learning laboratory initiative, which should be relevant to the broader scale interest in learning health systems.