Engineering Safe Care Journeys: Designing a Patient Safety Passport

The objective of this study was to use a participatory Human Factors Engineering (HFE) approach to identify key design guidelines and design requirements of a patient safety passport (PSP) to improve patient safety at care transition points along the patient journey.

We conducted a work system analysis and participatory design process to integrate the needs of multiple perspectives using cognitive interviews, contextual inquiry, team-based analysis, and codesign sessions.

We conducted semistructured interviews (N=29) with clinicians. We also conducted 20 contextual inquiry observations of older adult patients in the emergency department (ED) followed by 20 interviews with the ED clinicians who cared for those patients. We mapped the care transition process that included transitioning to the ED, being seen in the ED, and transitioning from the ED to the next location. We identified 21 categories representing the interaction of work system barriers and facilitators to safe ED care transitions. We identified 5 design guidelines, which provide the overarching conceptual characteristics of a PSP, and 5 design requirements to guide PSP design.

Our participatory HFE approach with a multidisciplinary design team identified key design guidelines and requirements for a PSP. Although this work was focused on the ED, a PSP is likely applicable to a range of care transition domains. Future work should seek to validate and refine PSP design requirements and guidelines across domains as part of a learning health system that can transform care transitions to be points of patient safety resilience.