# Engineering Safe Care Journeys for Vulnerable Older Adults

> **NIH AHRQ R18** · UNIVERSITY OF WISCONSIN-MADISON · 2021 · $617,663

## Abstract

Project Summary/Abstract
 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 201...

## Key facts

- **NIH application ID:** 10225289
- **Project number:** 5R18HS026624-04
- **Recipient organization:** UNIVERSITY OF WISCONSIN-MADISON
- **Principal Investigator:** MAUREEN A SMITH
- **Activity code:** R18 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2021
- **Award amount:** $617,663
- **Award type:** 5
- **Project period:** 2018-09-30 → 2023-07-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10225289

## Citation

> US National Institutes of Health, RePORTER application 10225289, Engineering Safe Care Journeys for Vulnerable Older Adults (5R18HS026624-04). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10225289. Licensed CC0.

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