This AHRQ-funded initiative aims to better understand barriers and facilitators to preventing, identifying, and resolving medication safety problems in transitions across levels of care within the healthcare system. We are utilizing a combination of patient and caregiver surveys and interviews, workflow analyses, and insights from a community-wide clinical dataset. Following data collection and synthesis, we will work with patients, providers, and staff together with a Community Advisory Board to design prototype interventions to overcome medication safety problems for older adults during transitions of care.

Ranjit Singh, MB BChir, MBA Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences
Huei-Yen (Winnie) Chen, PhD Department of Industrial Engineering, School of Engineering and Applied Sciences
David Jacobs, PharmD, PhD Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences

Robert Wahler, PharmD Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences
Jennifer Stoll, PhD Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences
Andrew Baumgartner, MD Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences
Sharon Hewner, RN, PhD School of Nursing
Ann Bisantz, PhD Department of Industrial Engineering, School of Engineering and Applied Sciences
Connor Wurst, PhD Department of Industrial Engineering, School of Engineering and Applied Sciences
Kenneth Joseph, PhD Department of Computer Science, School of Engineering and Applied Sciences
Haowen Hsu, PharmD, MPH Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences

Agency for Healthcare Research and Quality (AHRQ) - [9/1/2023 - 6/30/2027]

Medication harm is a significant issue in global health care, particularly for older adults during transitions of care (TOC). This proposed Learning Lab aims to address this by empowering patients and caregivers, in partnership with health care teams, to ensure safe medication use during and after TOC. The project will begin with an analysis of the existing medication safety work system, leading to the design, development, and testing of scalable, human-centered interventions. These interventions will be tested in a simulated environment before being piloted in a clinical setting.

The research team will follow a systems-engineering methodology to achieve two main aims. Aim 1 involves a multifaceted problem analysis to understand the causes and consequences of medication problems in TOC. This includes studying patients’ and caregivers’ experiences, performing cognitive engineering analysis, and using health information exchange data to identify risk factors for unplanned hospitalizations and medication harm.

Aim 2 involves the design, development, implementation, and evaluation of patient-driven interventions. These interventions will be designed with input from key stakeholders and evaluated in both simulated and clinical environments.

The ultimate goal is to develop a cross-system learning laboratory that brings together older adults, caregivers, researchers, and health care teams to protect them from medication harm. This approach focuses on patients and caregivers and engages them in every step of the process. The infrastructure and pilot data from this proposal will lay the groundwork for future studies to improve medication safety for older adults.

Active

• Chen HY*, Wurst C, Lattimer TA, Setiowati NG, Bisantz A, Wahler RG, Jacobs DM, Hewner S, Stoll J, Casucci S, Singh R. Challenges and Opportunities in the Medication Reconciliation Process in an Emergency Department: An Observational Human Factors Study. Challenges and Opportunities in the Medication Reconciliation Process in an Emergency Department: An Observational Human Factors Study. Journal of Patient Safety 21(7Supp):p S7-S11, October 2025. | DOI: 10.1097/PTS.0000000000001362

• Wurst C et al. Control Task Analysis of the Deprescription Process: A Pilot Study (paper presentation). 2023 Human Factors and Ergonomics Society International Annual Meeting, Washington, DC, Oct 2023.
• Wurst C et al. The Cognitive Work of Deprescribing: A Human Factors Pilot (poster presentation). United States Deprescribing Research Network (USDeN) 3rd Annual Meeting, Boston, MA, May 2024.
• Stoll, J., Wahler, A., Chen, H.Y.W., Jacobs, D.M., Hewner, S., Taylor, JS., Wahler, R.G., Singh, R.  Medication safety for older adults during transitions of care: patient and caregiver perspectives (poster presentation). 52nd Annual Meeting of the North American Primary Care Research Group, Québec, Canada. November 2024.
• Gazetta GG, Joseph K, Feuerstein S, Stoll J, Wahler RG, Bisantz A, Hewner S, Chen H-Y, Singh R. Jacobs DM. AI-Driven Solution for Reducing Polypharmacy Risks Following Hospital Discharge: A Predictive Model for Patient Medication Review (poster presentation). 2025 International Symposium on Human Factors and Ergonomics in Health Care. Toronto, Ontario, Canada. March 30 - April 2, 2025
• Setiowati NG, Wurst CG, Chen H-Y, Lattimer TG, Jacobs DM, Hewner S, Wahler A, Bisantz A, Stoll J, Wahler RG, Casucci S, Singh R. Medication Reconciliation in the Emergency Department: Work-as-Done vs. Work-as-Imagined (poster presentation). 2025 International Symposium on Human Factors and Ergonomics in Health Care. Toronto, Ontario, Canada. March 30 - April 2, 2025
• Lattimer, T. A., Wurst, C., Setiowati, N., Chen, H. Y. W., Bisantz, A., Wahler, R., Jacobs, D., Hewner, S., Stoll, J., Wahler, A., Casucci, S., & Singh, R. Patient-provider communication in the medication reconciliation process: An examination of barriers, facilitators, and implications for transitions of care in emergency medicine (poster presentation). The 8th Biennial D.C. Health Communication Conference (DCHC), Washington DC, May 1-3, 2025.
• Stoll J, Singh R,  Wahler A, Chen H-Y, Jacobs D, Wahler RG. Patient and Caregiver Perspectives on Medication Safety for Older Adults During Transitions of Care (poster presentation). American Geriatrics Society Annual Scientific Meeting, Chicago IL, May 7-19, 2025
• Lattimer, T. A., Stoll, J., Wahler, A., Tenzek, K. E., Wahler, R. G., Chen, H. Y., Jacobs, D. M., & Singh, R. Proposing the ALICE framework to improve medication safety through collaborative engagement: An analysis of older adult experiences during transitions of care (poster presentation). International Conference on Deprescribing, Montreal, Canada.  April 27-29, 2026.
• Workshop Presentation: Wurst, C., Chen, H.Y.W., Stoll, J., Wahler, A, Wahler, R.G., Bisantz, A, Littimer, T., Gazetta, G., Setiowati, N., Casucci, S., Jacobs, D., Hsu, H., Hewner, S., Singh, R. Interdisciplinary Triangulation of Geriatric Medication Safety Across Transition of Care. Advancing Systems and Practice Through Innovation, Research, and Education - Human Factors and Ergonomics Society Annual Meeting, Chicago, IL, United States. October 13-17, 2025.
• Platform Presentation: Wurst, C., Bisantz, A., Casucci, S., Chen, H.Y., Setiowati N., Sign, R., Wahler, R.G. Human Factors Analysis in Deprescribing Research and Practice. International Conference on Deprescribing, Montreal, Canada. April 27-29, 2026

• Podcast: Medication Overload with David Jacobs (L. Kaiser & University at Buffalo, Interviewers; season 2, episode 13). (2024, April 30). Retrieved April 30, 2024, from the Driven to Discover podcast series.
• Stakeholder Engagement Presentation: Wahler R, Stoll J, Singh R. Patient-Driven Medication Safety Learning Laboratory in Care Transitions AHRQ R18 (presentation). United States Deprescribing Research Network (USDeN), Quarterly Stakeholder Engagement Council Meeting, Mar 2024.