Engineering Safe Care Journeys: Designing a Patient Safety Passport.

Area of Science:

• Human Factors Engineering
• Patient Safety
• Health Systems Design

Background:

• Care transitions are critical points for potential patient harm.
• Existing systems often lack integrated patient information, leading to safety gaps.
• A patient safety passport (PSP) is proposed to improve information flow and safety during transitions.

Purpose of the Study:

• To identify design guidelines and requirements for a patient safety passport (PSP).
• To improve patient safety at care transition points using a participatory Human Factors Engineering (HFE) approach.
• To integrate the needs of multiple stakeholders in the PSP design process.

Main Methods:

• A work system analysis and participatory design process were employed.
• Methods included cognitive interviews, contextual inquiry, team-based analysis, and codesign sessions.
• Semistructured interviews with clinicians and observations of patients in the emergency department were conducted.

Main Results:

• 29 clinician interviews and 20 patient/clinician observations were completed.
• The care transition process within the emergency department was mapped.
• 21 categories of work system barriers/facilitators were identified, leading to 5 design guidelines and 5 design requirements for the PSP.

Conclusions:

• A participatory HFE approach successfully identified key PSP design elements.
• The developed guidelines and requirements are crucial for PSP design.
• While focused on the ED, PSPs have broader applicability across care transitions for enhanced patient safety resilience.