SEIPS 3.0: human-centered design of the patient journey for patient safety
Open accessAbstract
The Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models provide a framework for integrating Human Factors and Ergonomics (HFE) in health care quality and patient safety improvement. As care becomes increasingly distributed over space and time, the "process" component of the SEIPS model needs to evolve and represent this additional complexity. In this paper, we review different ways that the process component of the SEIPS models have been described and applied. We then propose the SEIPS 3.0 model, which expands the process component, using the concept of the patient journey to describe the spatio-temporal distribution of patients' interactions with multiple care settings over time. This new SEIPS 3.0 sociotechnical systems approach to the patient journey and patient safety poses several conceptual and methodological challenges to HFE researchers and professionals, including the need to consider multiple perspectives, issues with genuine participation, and HFE work at the boundaries.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Research syntheses argue that safety improvement depends on understanding how information flows, organisational routines, and technological artefacts co-evolve over time.
“For example, research syntheses argue that safety improvement depends on understanding how information flows, organisational routines, and technological artefacts co-evolve over time (16, 25).”
From Why digital health fails silently: a sociotechnical theory of health information technology–related risk (2026) · cites this paper as [25]
In “The SEIPS 3.0 Model – A Sociotechnical Systems Approach to Patient Journey” (page unavailable), the paper argues that understanding patient safety requires examining work systems over time as they adapt to changes in technology and work organization. “Working at the Interface” also discusses communication and information management across care settings. It does not, however, make the more specific claim that information flows, organisational routines, and technological artefacts co-evolve over time. (LLM, conf=0.81)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Donabedian, A. (1988) · JAMA · doi:10.1001/jama.260.12.1743 · Cited by 5,895 · see citing works
Rehospitalizations among Patients in the Medicare Fee-for-Service Program
Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009) · New England Journal of Medicine · doi:10.1056/nejmsa0803563 · Cited by 5,164 · see citing works
Medication Errors and Adverse Drug Events in Pediatric Inpatients
Kaushal, R. (2001) · JAMA · doi:10.1001/jama.285.16.2114 · Cited by 1,917 · see citing works
Work system design for patient safety: the SEIPS model
Carayon, P., Schoofs Hundt, A., Karsh, B.-T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006) · Quality in Health Care · doi:10.1136/qshc.2005.015842 · Cited by 1,795 · cited 5× · see citing works
“In the different visual representations of the SEIPS model (Carayon et al., 2006; Carayon et al., 2014b; Holden et al., 2013), the work system and the process are displayed separately.”
InfluentialSelf-citationImproving Diagnosis in Health Care
Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, & The National Academies of Sciences, E. (2015) · doi:10.17226/21794 · Cited by 1,376 · see citing works
The Competent Boundary Spanner
Williams, P. (2002) · Public Administration · doi:10.1111/1467-9299.00296 · Cited by 1,311 · cited 1× · see citing works
“Therefore, they must develop skills, knowledge and abilities to become “ competent boundary spanners ” (Williams, 2002), such as cultivating interpersonal relationships, communication skills, political skills and an ability to understand system interdependencies.”
Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., Hundt, A. S., Ozok, A. A., & Rivera-Rodriguez, A. J. (2013) · Ergonomics · doi:10.1080/00140139.2013.838643 · Cited by 1,221 · see citing works
Self-citationOn Teams, Teamwork, and Team Performance: Discoveries and Developments
Salas, E., Cooke, N. J., & Rosen, M. A. (2008) · Human Factors The Journal of the Human Factors and Ergonomics Society · doi:10.1518/001872008x288457 · Cited by 1,158 · see citing works
Patient- and Family-Centered Care and the Pediatrician's Role
(2012) · PEDIATRICS · doi:10.1542/peds.2011-3084 · Cited by 1,117 · see citing works
Bate, P., & Robert, G. (2006) · Quality and Safety in Health Care · doi:10.1136/qshc.2005.016527 · Cited by 1,081 · see citing works
A strategy for human factors/ergonomics: developing the discipline and profession
Dul, J., Bruder, R., Buckle, P., Carayon, P., Falzon, P., Marras, W. S., Wilson, J. R., & van der Doelen, B. (2012) · Ergonomics · doi:10.1080/00140139.2012.661087 · Cited by 931 · see citing works
Self-citationA Guide To Task Analysis: The Task Analysis Working Group
Kirwan, B., & Ainsworth, L. (1992) · Medical Entomology and Zoology · Cited by 919 · see citing works
Human factors systems approach to healthcare quality and patient safety
Carayon, P., Wetterneck, T. B., Rivera-Rodriguez, A. J., Hundt, A. S., Hoonakker, P., Holden, R., & Gürses, A. P. (2013) · Applied Ergonomics · doi:10.1016/j.apergo.2013.04.023 · Cited by 746 · see citing works
Self-citationHuman factors of complex sociotechnical systems
Carayon, P. (2006) · Applied Ergonomics · doi:10.1016/j.apergo.2006.04.011 · Cited by 617 · see citing works
Self-citationEvaluation of human work: A practical ergonomics methodology
Wilson, J. R., & Corlett, E. N. (1991) · Applied Ergonomics · doi:10.1016/0003-6870(91)90014-9 · Cited by 497 · see citing works
A balance theory of job design for stress reduction
Smith, M. J., & Sainfort, P. C. (1989) · International Journal of Industrial Ergonomics · doi:10.1016/0169-8141(89)90051-6 · Cited by 488 · see citing works
Microsystems in Health Care: Part 1. Learning from High-Performing Front-Line Clinical Units
Nelson, E. C., Batalden, P. B., Huber, T. P., Mohr, J. J., Godfrey, M. M., Headrick, L. A., & Wasson, J. H. (2002) · The Joint Commission Journal on Quality Improvement · doi:10.1016/s1070-3241(02)28051-7 · Cited by 451 · see citing works
Fundamentals of ergonomics in theory and practice
Wilson, J. R. (2000) · Applied Ergonomics · doi:10.1016/s0003-6870(00)00034-x · Cited by 442 · see citing works
Beyond usability: Designing effective technology implementation systems to promote patient safety
Karsh, B.-T. (2004) · Quality and Safety in Health Care · doi:10.1136/qshc.2004.010322 · Cited by 414 · see citing works
Process mapping the patient journey: an introduction
Trebble, T. M., Hansi, N., Hydes, T., Smith, M. A., & Baker, M. (2010) · BMJ · doi:10.1136/bmj.c4078 · Cited by 390 · see citing works
Karsh, B.-T., Holden, R. J., Alper, S. J., & Or, C. K. L. (2006) · Quality in Health Care · doi:10.1136/qshc.2005.015974 · Cited by 372 · see citing works
Operating at the Sharp End: The Complexity of Human Error
Cook, R. I., & Woods, D. D. (2018) · CRC Press eBooks · doi:10.1201/9780203751725-13 · Cited by 313 · see citing works
Carayon, P., Hancock, P. A., Leveson, N. G., Noy, I. Y., Sznelwar, L. I., & Hootegem, G. V. (2015) · Ergonomics · doi:10.1080/00140139.2015.1015623 · Cited by 312 · see citing works
Self-citationCare fragmentation, quality, and costs among chronically ill patients.
Frandsen, B., Joynt, K. E., Rebitzer, J. B., et al. (2015) · PubMed · Cited by 279 · see citing works
Validating a framework for participatory ergonomics (the PEF)
Haines, H., Wilson, J. R., Vink, P., & KONINGSVELD, E. A. P. (2002) · Ergonomics · doi:10.1080/00140130210123516 · Cited by 266 · see citing works
Improving Diagnosis in Health Care
(2016) · Military Medicine · doi:10.7205/milmed-d-15-00562 · Cited by 261 · see citing works
Khan, A., Spector, N. D., Baird, J. D., Ashland, M., Starmer, A. J., Rosenbluth, G., Garcia, B. M., Litterer, K. P., Rogers, J., Dalal, A. K., et al. (2018) · BMJ · doi:10.1136/bmj.k4764 · Cited by 241 · see citing works
An integrated patient journey mapping tool for embedding quality in healthcare service reform
McCarthy, S., O’Raghallaigh, P., Woodworth, S., Lim, Y. L., Kenny, L. C., & Adam, F. (2016) · Journal of Decision Systems · doi:10.1080/12460125.2016.1187394 · Cited by 209 · see citing works
Handbook of human factors and ergonomics in health care and patient safety
Finnerty, J. (2012) · Ergonomics · doi:10.1080/00140139.2012.740845 · Cited by 206 · see citing works
The Balance Theory and the Work System Model … Twenty Years Later
Carayon, P. (2009) · International Journal of Human-Computer Interaction · doi:10.1080/10447310902864928 · Cited by 188 · see citing works
Self-citationCare Coordination for Children With Medical Complexity: Whose Care Is It, Anyway?
Kuo, D. Z., McAllister, J. W., Rossignol, L., Turchi, R. M., & Stille, C. J. (2018) · Pediatrics · doi:10.1542/peds.2017-1284g · Cited by 182 · see citing works
Safer Healthcare : Strategies for the Real World
Vincent, C. A., & Amalberti, R. (2016) · OAPEN (The OAPEN Foundation) · Cited by 181 · see citing works
Culture, politics and ergonomics
Moray, N. P. (2000) · Ergonomics · doi:10.1080/001401300409062 · Cited by 177 · see citing works
Collaborative design: Managing task interdependencies and multiple perspectives
Détienne, F. (2005) · Interacting with Computers · doi:10.1016/j.intcom.2005.05.001 · Cited by 159 · see citing works
Crossing levels in systems ergonomics: A framework to support ‘mesoergonomic’ inquiry
Karsh, B., Waterson, P. E., & Holden, R. J. (2013) · Applied Ergonomics · doi:10.1016/j.apergo.2013.04.021 · Cited by 150 · see citing works
Patient safety - the role of human factors and systems engineering.
Carayon, P., & Wood, K. E. (2010) · PubMed · Cited by 147 · see citing works
Self-citationInternational Encyclopedia of Ergonomics and Human Factors
Guha, M. (2001) · Reference Reviews · doi:10.1108/rr.2001.15.7.33.390 · Cited by 140 · see citing works
Learning Through Citizen Science
Board on Science Education, Education, D. O. B. A. S. S. A., & National Academies of Sciences, E. (2018) · National Academies Press eBooks · doi:10.17226/25183 · Cited by 139 · see citing works
Citizen Science: New Research Challenges for Human–Computer Interaction
Preece, J. (2016) · International Journal of Human-Computer Interaction · doi:10.1080/10447318.2016.1194153 · Cited by 135 · see citing works
From Tasks To Processes: The Case For Changing Health Information Technology To Improve Health Care
Walker, J. M., & Carayon, P. (2009) · Health Affairs · doi:10.1377/hlthaff.28.2.467 · Cited by 122 · see citing works
Self-citationA Family-Centered Rounds Checklist, Family Engagement, and Patient Safety: A Randomized Trial
COX, E. D., Jacobsohn, G. C., Rajamanickam, V., Carayon, P., Kelly, M. M., Wetterneck, T. B., Rathouz, P. J., & Brown, R. (2017) · PEDIATRICS · doi:10.1542/peds.2016-1688 · Cited by 103 · see citing works
Self-citationHolden, R. J., Valdez, R. S., Schubert, C. C., Thompson, M. J., & Hundt, A. S. (2016) · Ergonomics · doi:10.1080/00140139.2016.1168529 · Cited by 92 · see citing works
Self-citationSafety analysis over time: seven major changes to adverse event investigation
Vincent, C. A., Carthey, J., Macrae, C., & Amalberti, R. (2017) · Implementation Science · doi:10.1186/s13012-017-0695-4 · Cited by 75 · see citing works
Arbaje, A. I., Kansagara, D. L., Salanitro, A. H., Englander, H. L., Kripalani, S. B., Jencks, S. F., & Lindquist, L. A. (2014) · Journal of General Internal Medicine · doi:10.1007/s11606-013-2729-1 · Cited by 66 · see citing works
Patient healthcare trajectory. An essential monitoring tool: a systematic review
Pinaire, J., Azé, J., Bringay, S., & Landais, P. (2017) · Health Information Science and Systems · doi:10.1007/s13755-017-0020-2 · Cited by 63 · see citing works
Karsh, B., & Brown, R. (2010) · Applied Ergonomics · doi:10.1016/j.apergo.2009.12.007 · Cited by 61 · see citing works
Xiao, Y., Parker, S. H., & Manser, T. (2013) · Reviews of Human Factors and Ergonomics · doi:10.1177/1557234x13495181 · Cited by 57 · see citing works
Strategies for improving family engagement during family‐centered rounds
Kelly, M. M., Xie, A., Carayon, P., DuBenske, L. L., Ehlenbach, M. L., & COX, E. D. (2013) · Journal of Hospital Medicine · doi:10.1002/jhm.2022 · Cited by 52 · see citing works
Self-citationApplication of participatory ergonomics to the redesign of the family-centred rounds process
Xie, A., Carayon, P., COX, E. D., Cartmill, R. S., Li, Y., Wetterneck, T. B., & Kelly, M. M. (2015) · Ergonomics · doi:10.1080/00140139.2015.1029534 · Cited by 50 · see citing works
Self-citationToward a process-level view of distributed healthcare tasks: Medication management as a case study
Werner, N. E., Malkana, S., Gürses, A. P., Leff, B. A., & Arbaje, A. I. (2017) · Applied Ergonomics · doi:10.1016/j.apergo.2017.06.020 · Cited by 47 · see citing works
Examining situated design practices: Nurses' transformations towards genuine participation
Østergaard, K. L., Simonsen, J., & Karasti, H. (2018) · Design Studies · doi:10.1016/j.destud.2017.12.002 · Cited by 40 · see citing works
Multi-stakeholder collaboration in the redesign of family-centered rounds process
Xie, A., Carayon, P., Cartmill, R. S., Li, Y., COX, E. D., Plotkin, J. A., & Kelly, M. M. (2014) · Applied Ergonomics · doi:10.1016/j.apergo.2014.07.011 · Cited by 34 · see citing works
Self-citation(2006) · CRC Press eBooks · doi:10.1201/9780849375477-419 · Cited by 27 · see citing works
The Role of Care Coordinators in Improving Care Coordination: The Patient's Perspective
Fryer, A.-K. (2012) · Archives of Internal Medicine · doi:10.1001/archinternmed.2012.212 · Cited by 26 · see citing works
Carayon, P., Li, Y., Kelly, M. M., DuBenske, L. L., Xie, A., McCabe, B. C., Orne, J., & COX, E. D. (2014) · Applied Ergonomics · doi:10.1016/j.apergo.2014.05.001 · Cited by 24 · see citing works
Self-citationPatient Flow Analysis in Resource-Limited Settings: A Practical Tutorial and Case Study
Dixon, C. A., Punguyire, D., Mahabee‐Gittens, M., Ho, M. L., & Lindsell, C. J. (2015) · Global Health Science and Practice · doi:10.9745/ghsp-d-14-00121 · Cited by 22 · see citing works
Improving Patient Safety in the Patient Journey: Contributions from Human Factors Engineering
Carayon, P., & Wooldridge, A. R. (2019) · Women in engineering and science · doi:10.1007/978-3-030-11866-2_12 · Cited by 20 · see citing works
Self-citationError Reduction as a Systems Problem
Moray, N. (2018) · CRC Press eBooks · doi:10.1201/9780203751725-5 · Cited by 19 · see citing works
Kianfar, S., Carayon, P., Hundt, A. S., et al. (2019) · Applied Ergonomics · doi:10.1016/j.apergo.2019.05.002 · Cited by 16 · see citing works
Self-citationWomen in Industrial and Systems Engineering : Key Advances and Perspectives on Emerging Topics
Smith, A. E. (2019) · Cited by 15 · see citing works
The nurse-patient trajectory framework.
Alexander, G. L. (2007) · PubMed · Cited by 13 · see citing works
Brennan, P. F., & Safran, C. (2004) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2004.05.005 · Cited by 10 · see citing works
Partial truths in the pursuit of patient safety
Henriksen, K. (2010) · BMJ Quality & Safety · doi:10.1136/qshc.2010.041293 · Cited by 8 · see citing works
Integrating Ergonomics and Quality Concepts
(2015) · CRC Press eBooks · doi:10.1201/b18362-47 · Cited by 6 · see citing works
Medication Error Propagation In Intensive Care Units
Carayon, P., Ju, F., Cartmill, R. S., et al. (2015) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931215591111 · Cited by 5 · see citing works
Self-citationThe Artichoke Systems Approach for Identifying the Why of Error
Carayon, P. (2006) · doi:10.1201/9781482269505-16 · Cited by 4 · see citing works
Self-citation(2015) · CRC Press eBooks · doi:10.1201/b18362-44 · Cited by 4 · see citing works
Handoffs and Transitions of Care
Wears, R. L., Perry, S. J., & Patterson, E. S. (2011) · CRC Press eBooks · doi:10.1201/b11219-18 · Cited by 3 · see citing works
Book Review: Physicians as Leaders: Who, How and Why Now?
Breitbart, R. E. (2006) · American Journal of Medical Quality · doi:10.1177/1062860606288485 · Cited by 2 · see citing works
Flagged first, then by citations
Research works printed but not linked: 4
- Carayon P, DuBenske LL, McCabe BC, Shaw B, Gaines ME, Kelly MM, … Cox ED (2011). Work system barriers and facilitators to family engagement in rounds in a pediatric hospital In Albolino S, Bagnara S, Bellandi T, Llaneza J, Rosal G, & Tartaglia R (Eds.), Healthcare Systems Ergonomics and Patient Safety 2011 (pp. 81– 85). Boca Raton, FL: CRC Press.
- Kirwan B, & Ainsworth LK (1992). A Guide to Task Analysis. London: Taylor & Francis.
- Matthieu JE, Marks MA, & Zaccaro SJ (2001). Multiteam systems In Anderson N (Ed.), Handbook of Industrial, Work and Organizational Psychology (pp. 289– 313).
- NASEM (National Academies of Sciences, E., and Medicine). (2018a). Crossing the Global Quality Chasm. Retrieved from Washington DC: 30605296
Cited by
Sorted by citations
Trust in AI: why we should be designing for APPROPRIATE reliance
Benda, N. C., Novak, L. L., Reale, C., & Ancker, J. S. (2021) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocab238 · Cited by 76 · see citing works
Dunn Lopez, K., Chin, C.-L., Leitão Azevedo, R. F., Kaushik, V., Roy, B., Schuh, W., Banks, K., Sousa, V., & Morrow, D. (2021) · Applied Ergonomics · doi:10.1016/j.apergo.2021.103359 · Cited by 62 · see citing works
Kanaparthy, N. S., Villuendas-Rey, Y., Bakare, T., Diao, Z., Iscoe, M., Loza, A., Wright, D., Safranek, C., Faustino, I. V., Brackett, A., et al. (2025) · JMIR AI · doi:10.2196/76743 · Cited by 57 · see citing works
Bowditch, L., Molloy, C., King, B., Abedi, M., Jackson, S., Bierbaum, M., Yu, Y., Raggett, L., Salmon, P., Braithwaite, J., et al. (2026) · BMJ Quality & Safety · doi:10.1136/bmjqs-2025-019063 · Cited by 16 · see citing works
Jabin, M. S. R. (2026) · Frontiers in Digital Health · doi:10.3389/fdgth.2026.1785086 · Cited by 10 · see citing works
The Problem with How We View Medical (and Diagnostic) Error in Emergency Medicine
Ladell, M. M., Jacobson, N. L., Yale, S. C., McDermott, K. L., Papautsky, E. L., Catchpole, K. R., & Scanlon, M. C. (2025) · Academic Emergency Medicine · doi:10.1111/acem.15076 · Cited by 8 · see citing works
Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors
Yen, C., Epling, J. W., Rockwell, M., & Vaughn-Cooke, M. (2026) · Diagnostics · doi:10.3390/diagnostics16020347 · Cited by 6 · see citing works
Grant, C., Gephart, S. M., & Rattray, N. (2024) · Nursing for Women's Health · doi:10.1016/j.nwh.2024.02.006 · Cited by 2 · see citing works
Senior, M. A., Alfred, M., Akintunde, T., & Montague, E. (2026) · Ergonomics · doi:10.1080/00140139.2026.2740202
- Authors
- Carayon, P., Wooldridge, A., Hoonakker, P., Hundt, A. S., & Kelly, M. M.
- Affiliations
- University of Wisconsin–Madison (US)
- University of Illinois Urbana-Champaign (US)
- Corresponding author
- Carayon, Pascale
- Venue
- Applied Ergonomics
- Publisher
- Elsevier BV
- Published
- 2020-04
- Volume
- 84
- Pages
- 103033
- ISSN
- 0003-6870 (ISSN-L)
- PMC
- PMC7152782
- OpenAlex
- W2999992662
- Cited by
- 493
- References
- 69
- Citations by year
- 2026: 120 · 2025: 99 · 2024: 72 · 2023: 64 · 2022: 64 · 2021: 50 · 2020: 22 · 2012: 1
- FWCI
- 46.78
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Applied Ergonomics (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Physical Sciences › Engineering › Biomedical Engineering › Ergonomics and Human Factors
- Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
- Keywords
- SEIPS model, patient journey, patient safety, human factors and ergonomics, socio-technical systems, process of care
- MeSH terms
- Humans, Ergonomics, Models, Theoretical, Quality of Health Care, Systems Analysis, Task Performance and Analysis, Safety Management, Medical Errors, Quality Improvement, Patient Safety
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
