# Patient-Driven Medication Safety Learning Laboratory in Care Transitions

> **NIH AHRQ R18** · STATE UNIVERSITY OF NEW YORK AT BUFFALO · 2024 · $494,491

## Abstract

Project Summary/Abstract
Medication harm is a leading cause of injury and avoidable harm in health care systems across the world. This
is especially true for older adults, who are at higher risk for medication harm, especially around transitions of
care (TOC), as they often take multiple medicines and have several changes made to their medicines during
inpatient admission. There are major gaps and barriers for older adult patients and caregivers to achieve safe
medication use during and after care transitions. This proposed Learning Lab will empower patients and
caregivers in partnership with the healthcare system team, starting with analyzing the existing medication
safety work system, spanning the entire transition of care. This will lead to the design, development, and
testing of scalable human-centered interventions in a simulated environment with input from practicing
clinicians and patients as the end-users, followed by pilot testing in the clinical environment. To accomplish
this, the research team will follow the five-phase, systems-engineering methodology to achieve the following
aims: Aim 1: Problem Analysis – This aim uses a multifaceted approach to identify and understand the
causes and consequences of medication problems in transitions of care, including the needs and priorities of
patients and caregivers, and the operational complexities that shape and constrain care transition work. The
team will: Aim 1(a) study patients’ and caregivers’ experiences with recent hospitalizations, focusing on
medication changes, associated symptoms, and Social Determinants of Health-related challenges; Aim 1(b)
perform cognitive engineering analysis to identify cognitive work challenges and their associated information
needs involved in the care transition work at hospital and primary care sites; and Aim 1(c) use health
information exchange (HIE) data to identify patient- and system-level risk factors and develop risk algorithms
for unplanned hospitalizations and medication harm. Aim 2: (a) Design, Development, (b) Implementation,
and Evaluation. The team will: Aim 2(a) iteratively design and develop patient-driven interventions with inputs
from key stakeholders (e.g., members of the project’s Community Advisory Board); and Aim 2(b) implement
and evaluate promising solutions—first in a simulated environment (with realistic tasks) and subsequently in a
clinical setting. The overall goal of this proposal is to develop a cross-system learning laboratory that brings
together older adults, caregivers, researchers, and healthcare teams in innovative ways to protect them from
medication harm. Our approach puts the focus on patients and caregivers, with attention to the Social
Determinants of Health, and engages them extensively in every step of the systems engineering process. The
learning laboratory infrastructure and pilot data from this proposal will create a strong foundation for sustained
stakeholder partnership that will spawn future funded studies to...

## Key facts

- **NIH application ID:** 10916491
- **Project number:** 5R18HS029122-02
- **Recipient organization:** STATE UNIVERSITY OF NEW YORK AT BUFFALO
- **Principal Investigator:** Heui-Yen Chen
- **Activity code:** R18 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2024
- **Award amount:** $494,491
- **Award type:** 5
- **Project period:** 2023-09-01 → 2027-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10916491

## Citation

> US National Institutes of Health, RePORTER application 10916491, Patient-Driven Medication Safety Learning Laboratory in Care Transitions (5R18HS029122-02). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10916491. Licensed CC0.

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