The Patient Safety Learning Lab 2 (PSLL2) at the Children’s Hospital of Philadelphia (CHOP) is a four-year, AHRQ-funded initiative aimed at improving communication and safety during interdepartmental patient transfers. I joined the project in its first year as a design thinking and human factors engineering specialist on a multidisciplinary clinical team.

Observations revealed communication breakdowns, inconsistent handoff protocols, and documentation errors, increasing the risk of delays and patient safety incidents.

Extensive observations and interviews were conducted to understand communication gaps during patient transfers. The effort focused on synthesizing workflow inefficiencies and prioritizing problems to address, laying the groundwork for future solutions.

The project is currently in its second year, with early findings shaping the development of solutions to enhance transfer safety and efficiency.