The DOI matches its Crossref record; 49 of the 53 references it cites were found in a registry or an index; none of the 35 sources its claims cite is checked for support yet.
Work system design for patient safety: the SEIPS model
Open accessAbstract
Models and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper we describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described.
Overview
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Claims the paper makes
63 Own interpretation · 26 Sources not found · 9 No full text of the sources · 9 Own result · 4 No basis given
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Tasks, tools, and organization coincide with an issue repeatedly reported by staff concerning the process of obtaining clinical information on patients in a timely fashion.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Likewise, quality and safety issues identified were related to insufficient and potentially inaccurate information then collected because of the last minute nature of these clinical assessments.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
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The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Staff responses to the questionnaire were also associated with various processes (including care processes) and outcomes.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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In the paper
“Staff responses to the questionnaire can be associated with numerous aspects of the work system.29”
What the sources say
- Not matchedcites [29] 29. Carayon P, Gurses AP, Hundt AS, et al. Performance obstacles and facilitators of healthcare providers. In: Korunka C, Hoffmann P, eds. Change and quality in human service work. Munich: Hampp Publishers, 2005:257-76.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“and nesting itself in a model familiar to many health care professionals-namely, Donabedian's quality model.11 12”
What the sources say
- Not matchedcites 11 12
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“As a result, components of the work system (such as the organization or the environment) and their interdependencies may be overlooked or underemphasized.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
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In the paper
“The interactions between the various components ''produce'' different outcomes: performance, safety and health, and quality of working life.”
What the sources say
- Not matchedcites [5][6][7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
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- Not matched
In the paper
“Donabedian's model explicitly links the structure and processes of care to subsequent patient outcomes.”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Assessing patient safety and designing systems that produce safe patient care can be accomplished by using the SEIPS model that integrates Donabedian's structure-processoutcome (SPO) framework and the work system model (fig 1).”
plaindirect- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model builds on this idea by showing how work system design (structure) is linked to patient safety (outcome) through care processes.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- Probably not a substantial claim. 66
- It may state two separate claims as one. 20
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They also emphasized coordination issues related to patient information.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Likewise, it was easier to understand comments on the staff questionnaire concerning the work space.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They commented about the low quality of communication with patients regarding preoperative preparation (for example, understanding of instructions) and postoperative recovery (for example, inconsistencies in providers' instructions).”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, unavailability of patient related information sometimes can lead to cancellations of surgeries on the day they are scheduled.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“A review of the floor plans helped the research team further understand the reasons for these concerns.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Staff offered suggestions to remedy this problem through redesign of forms and changes in policy and job design.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Here staff conveyed the inherent inefficiencies of tracking down information that should have been previously provided.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, concern was expressed by staff regarding the lack of privacy for patients and high noise levels.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This gave us greater insight concerning the expectations for the various positions as well as how each centre was organized according to the various tasks.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“In this case the plans provided an understanding of the work flow and offered a greater appreciation for the confidentiality issues identified during the patient shadowing.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“We suggest that the work system model applied to patient safety complements and expands Donabedian's framework.”
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Changes to any aspect of the work system will, depending on how the change or improvement is designed and implemented, either negatively or positively affect the work and clinical processes and the consequent patient, employee, and organizational outcomes.”
plainconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper may give no reason why it holds.
In the paper
“The discipline of human factors emphasizes interactions between people and their environment that contribute to performance, safety and health, and quality of working life, and the goods or services produced.13 14”
What the sources say
- Not matchedcites 13 14
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“In Donabedian's model, the structure includes the organizational structure (work system model component = organization); the material resources (work system model components = environment, technology/tools); and the human resources (work system model components = care provider, tasks).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Overall, the work system in which care is provided affects both the work and clinical processes, which in turn influence the patient, employee, and organizational outcomes of care.”
plaindirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“our SEIPS model does not highlight any single element of the work system.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“According to the work system model, a person (the person could be a care provider, another employee of a healthcare institution such as a biomedical engineer, a unit clerk, or the patient) performs a range of tasks using various tools and technologies.”
What the sources say
- Not matchedcites [5][6][7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“Donabedian 20 concludes that direct relationships may exist between structure, process and outcome.”
What the sources say
- Not matchedcites [20] 20. Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press, 1980.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
hedgedconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This reflects the fact that most of the focus of the SPO model centres on the providers and their relationship with the processes and outcome(s)-that is, quality is assessed by the way in which care is provided by an individual or care team as well as the outcome of the care.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Donabedian's two other means of assessing quality include evaluating the process(es) of care (how provider tasks and clinical processes are both organized and performed) and evaluating the outcome(s) of care (assessing the clinical results and impacts of and patient satisfaction with the care provided).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The implication is, therefore, that aspects of the structure may be of lesser consequence.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“According to Donabedian's model, poor quality, in turn, results by not following what is defined as the appropriate or correct means of performing a task (poor process).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“In Donabedian's model, however, there is a clear statement that ''we must begin … with the performance of physicians and other health care providers''.19”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
boosted- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“The performance of these tasks occurs within a certain physical environment and under specific organizational conditions.”
What the sources say
- Not matchedcites [5][6][7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is important to recognize that a healthcare work system often includes both healthcare providers and the patient being cared for.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The fact that the SEIPS model explains how the design of a system can impact patients, employees, and the organization has its roots in the theory of healthy work organizations (HWOs).”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The work system model also allows linkage of the various elements of the structure in the SPO model-that is, the organizational structure and material and human resources.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It proposes the work system model as an expansion of the structure by addressing elements of the work system model such as the physical environment, organizational culture and climate, error reporting and analysis, and work design that are so much a part of the current patient safety focus.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model specifies feedback loops from processes to work system and from outcomes to work system.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Any healthcare work system can therefore involve multiple individuals such as healthcare providers and patients.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“However, it has been noted that physician professionalism also fosters a ''culture of blame'' when things go wrong because, if physicians are responsible for the entire medical process, then they are also exclusively to blame for poor quality care.26”
What the sources say
- Not matchedcites [26] 26. Leape LL. Error in medicine. JAMA 1994;272:1851-7.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
hedgeddirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
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In the paper
“Professionals such as physicians, nurses, pharmacists, and other licensed healthcare providers are bound by ethical mandates to serve in their clients' best interests.25”
What the sources say
- Not checked — no full text of the sourcecites [25] 25. ABIM Foundation. ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-6. source
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, a care process can be considered as a series of steps or tasks performed by an individual or a team of individuals using various technologies and tools; the care process may involve various locations, therefore different physical environments.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“A system redesign approach to changing physician behavior may not only be a more effective approach, but may be better accepted by physicians than traditional organizational efforts to improve quality using incentives.27”
What the sources say
- Not checked — no full text of the sourcecites [27] 27. Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health- System Pharm 2002;59:436-46. source
hedgedconditional- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Poor processes and outcomes can be triggers for system redesign: the need would then arise to identify negative work system elements that affect processes and the quality and safety of care, as well as employee and organizational outcomes.”
hedgeddirect- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
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Probably not a substantial claim. It may be too vague to check against evidence.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The patient is also involved in patient care processes and is the ''recipient'' of good or bad outcomes of the care process.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
In the paper
“HWOs are organizations that have both good organizational outcomes and a healthy and safe workforce.31 32”
What the sources say
- Not matchedcites 31 32
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“From this viewpoint, the patient is an ''input'' into the SEIPS model.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Some negative elements in a work system that are hard to change may be overcome by focusing on some other positive elements.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Conversely, patient safety activities place greater emphasis on the system in which practitioners work and less on individual performance.21”
What the sources say
- Not checked — no full text of the sourcecites [21] 21. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43. source
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, the PICC line intervention may not decrease the nurse's workload but add to the workload as more and more patients require PICC line insertion rather than central venous catheter insertions.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Our model emphasizes the linkages between patient outcomes and employee/organizational outcomes.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“In the SEIPS model the individual is at the centre of the work system.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These system redesigns support rather than conflict with the physician's role as a professional.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The implication is that outcomes (both patient and employee/organizational, as proposed by the SEIPS model) are related and that they also are associated with structure aspects of the SPO model.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These feedback loops represent pathways to design or redesign the work system.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The care process is also affected by multiple organizational characteristics such as the need for coordination and collaboration among the healthcare providers involved in the process.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Donabedian's model focuses on care process(es)-that is, how care is provided, delivered and managed.”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
- Not matched
In the paper
“Likewise, a bad outcome is associated with the poor performance of an individual (or a group of individuals).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, a care process can be considered as a series of steps or tasks performed by an individual or a team of individuals using various technologies and tools; the care process may involve various locations, therefore different physical environments.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Firstly, if the individual in the work system is a healthcare provider, tasks performed by the individual often involve the patient-for example, surgical tasks.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Using the SEIPS model with the patient at the centre of the work system model can help to identify deficiencies in the healthcare system that can impair the patient's capacity to receive high quality safe care, and therefore contribute to the design of systems and processes for delivering patient centred care.”
plainconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
In the paper
“Involvement of physicians in the system redesign process is critical to both the success of the system and to physician acceptance of the new system.26”
What the sources say
- Not matchedcites [26] 26. Leape LL. Error in medicine. JAMA 1994;272:1851-7.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model expands the concept of process to include not only care processes but also other processes that support the care process such as maintenance, housekeeping and supply chain management.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“6thers have also emphasized the important relationship between patient outcomes and employee/organizational outcomes.15 33”
What the sources say
- Not matchedcites 15 33
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It can be used proactively to guide system design and hazard analysis, or reactively to guide patient or employee injury investigations.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The design of work systems affects patient safety as well as employee and organizational outcomes.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is descriptive, not prescriptive.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This can be considered as a limitation of the model because it does not provide specific guidance as to the critical elements; but it can also be a strength because the model is generic and adaptable to the particular context or situation.”
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The individual is at the centre of the work system and can be a healthcare provider, a healthcare team, or the patient.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, it provides a framework on how to think about the different aspects of a work system, their interactions, and possible outcomes.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
In the paper
“The professional model assumes that providers have the ultimate authority to define and carry out the core tasks of providing medical care.42”
What the sources say
- Not matchedcites [42] 42. Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Harper & Row, 1970.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
- Not matched
In the paper
“Recognizing potential resistance and obtaining strong support from key opinion leaders 43 is essential to effective implementation of the SEIPS model.”
What the sources say
- Not checked — no full text of the sourcecites [43] 43. Flynn KE, Smith MA, Davis MK. From physician to consumer: the effectiveness of strategies to manage health care utilization. Med Care Res Rev 2002;59:455-81. source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It can also guide patient safety researchers toward developing research questions and understanding what variables to measure for a particular study.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Because the professional status of providers is linked so strongly to their autonomy, they may resist system efforts to manage the process of medical care as infringing on their autonomy and degrading their professional status.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This can be considered as a limitation of the model because it does not provide specific guidance as to the critical elements; but it can also be a strength because the model is generic and adaptable to the particular context or situation.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“We have shown that the SEIPS model can be applied in many different ways to patient safety challenges.”
boosted- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is critical to understand how resistance to a systems approach may limit effective implementation of the SEIPS model in practice.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The design of work systems influences processes which, in turn, affect outcomes.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model is useful for providing a view of the whole system instead of focusing on only one aspect of the work system and treating that aspect in isolation.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They also influence each other.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
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?
In the citing paper
“Detecting and preventing EHR-related safety concerns is challenging because concerns are often multifaceted, involving not only potentially unsafe technological features of the EHR but also EHR user behaviors, organizational characteristics, and rules and regulations that guide EHR-related activities.”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [27]
In the citing paper
“In addition, conceptual frameworks or models have been developed to incorporate the breadth of technical and non-technical factors into the analysis of EHR safety and effectiveness.21 25 27 32 33”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [27]
In the citing paper
“Another systematic review of the effect of EHR use on the quality of outpatient care came to a similarly negative conclusion.29”
From EHR Safety: The Way Forward to Safe and Effective Systems (2008) · cites this paper as [29]
Citations
Cites
Institute of Medicine (2000) · National Academies Press eBooks · doi:10.17226/9728 · Cited by 14,390
Crossing the Quality Chasm: A New Health System for the 21st Century
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To Err is Human: Building a Safer Health System
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Crossing the Quality Chasm: A New Health System for the 21st Century
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Evaluating the quality of medical care
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Evaluating the Quality of Medical Care
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Profession of Medicine: A Study of the Sociology of Applied Knowledge.
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Cited by
Sorted by citations
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
“In the US, a prevalent healthcare human factors model of person-centered sociotechnical systems is the framework introduced by Carayon and colleagues in the University of Wisconsin’s Systems Engineering Initiative for Patient Safety (SEIPS) (Carayon et al., 2006; Carayon et al., 2013).”
BackgroundSelf-citationSittig, D. F., & Singh, H. (2010) · Quality and Safety in Health Care · doi:10.1136/qshc.2010.042085 · Cited by 897
“Third, Carayon's Systems Engineering Initiative for Patient Safety model”
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 814
“…et al., 2005a; Hoonakker et al., 2010; Hoonakker et al., 2011), observation methodology (Carayon et al., 2005d; Carayon et al., 2007b), interviews (Carayon et al., 2006a; Gurses and Carayon, 2009), and proactive risk assessment of healthcare processes (Carayon et al., 2011e; Hundt et al., 2013;…”
BackgroundMethodInfluentialSelf-citationKoppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m2616 · Cited by 685
“When possible, subsequent interviews and our participation in meetings for FMEA, morbidity and mortality conferences, and BCMA implementation also helped validate the candidate workarounds and their causes. Only workarounds and their causes that were actually observed, reported, or documented are included in this anal…”
MethodSelf-citationLean Thinking in Emergency Departments: A Critical Review
Holden, R. J. (2011) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2010.08.001 · Cited by 516
SEIPS 3.0: human-centered design of the patient journey for patient safety
Carayon, P., Wooldridge, A., Hoonakker, P., Hundt, A. S., & Kelly, M. M. (2020) · Applied Ergonomics · doi:10.1016/j.apergo.2019.103033 · Cited by 493
“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-citationMeasuring workload of ICU nurses with a questionnaire survey: the NASA Task Load Index (TLX)
Hoonakker, P., Carayon, P., Gürses, A. P., Brown, R., Khunlertkit, A., McGuire, K., & Walker, J. M. (2011) · IIE Transactions on Healthcare Systems Engineering · doi:10.1080/19488300.2011.609524 · Cited by 387
“There are several frameworks that can be used to determine possible causes of nurses’ workload, for example, the work-system model (Carayon et al., 2006; Carayon, 2009).”
Self-citationHealth information technology: fallacies and sober realities
Karsh, B.-T., Weinger, M. B., Abbott, P. A., & Wears, R. L. (2010) · Journal of the American Medical Informatics Association · doi:10.1136/jamia.2010.005637 · Cited by 365
“Because information presentation profoundly affects user behavior and decision-making, it is critical that information displays be thoughtfully designed and rigorously tested to ensure they yield the best possible performance outcomes. These evaluations must consider the full complexity of the context in which the sys…”
BackgroundSelf-citationInterruptions and distractions in healthcare: review and reappraisal
Rivera-Rodriguez, A. J., & Karsh, B.-T. (2010) · BMJ Quality & Safety · doi:10.1136/qshc.2009.033282 · Cited by 363
“provide a good start by conceptualising interruptions as a system of events and agents and providing a useful set of interruption attributes. However, we feel that a complex sociotechnical systems approach”
BackgroundSelf-citationOr, C. K., Karsh, B., Severtson, D. J., Burke, L. J., Brown, R., & Brennan, P. F. (2010) · Journal of the American Medical Informatics Association · doi:10.1136/jamia.2010.007336 · Cited by 326
“Applying usability principles is necessary but not sufficient to achieve useful CHIT; cognitive analyses and user involvement provide the ‘what’ to design; usability principles and principles of data representation for problem solving”
Self-citationGan, W. H., Lim, J. W., & Koh, D. S. Q. (2020) · Safety and Health at Work · doi:10.1016/j.shaw.2020.03.001 · Cited by 298
“The Systems Engineering Initiative for Patient Safety (SEIPS) is a human factors e based model used in health care to understand the impact of a work system and processes on outcomes [10].”
Kilsdonk, E., Peute, L., & Jaspers, M. (2016) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2016.12.001 · Cited by 303
Musuuza, J., Sutherland, B. L., Kurter, S., Balasubramanian, P., Bartels, C. M., & Brennan, M. B. (2020) · Journal of Vascular Surgery · doi:10.1016/j.jvs.2019.08.244 · Cited by 274
Vincent, C., & Amalberti, R. (2016) · doi:10.1007/978-3-319-25559-0 · Cited by 278
Sørensen, J. L., Østergaard, D., LeBlanc, V. R., Ottesen, B., Konge, L., Dieckmann, P., & van der Vleuten, C. P. M. (2017) · BMC Medical Education · doi:10.1186/s12909-016-0838-3 · Cited by 272
“equipment, guidelines and the physical clinical environment [33].”
BackgroundInterventions to increase patient portal use in vulnerable populations: a systematic review
Grossman, L. V., Masterson Creber, R. M., Benda, N. C., Wright, D., Vawdrey, D. K., & Ancker, J. S. (2019) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocz023 · Cited by 251
Human factors and ergonomics as a patient safety practice
Carayon, P., Xie, A., & Kianfar, S. (2013) · BMJ Quality & Safety · doi:10.1136/bmjqs-2013-001812 · Cited by 304
Self-citationAusserhofer, D., Schubert, M., Desmedt, M., Blegen, M. A., Geest, S. D., & Schwendimann, R. (2012) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2012.04.007 · Cited by 252
“1) describes how organizational features are related to patient outcomes and builds on the System Engineering Initiative for Patient Safety model (Carayon et al., 2006) and the Rationing of nursing care in Switzerland model (Schubert et al.”
BackgroundIn Situ Simulation in Continuing Education for the Health Care Professions: A Systematic Review
Rosen, M. A., Hunt, E. A., Pronovost, P. J., Federowicz, M. A., & Weaver, S. J. (2012) · Journal of Continuing Education in the Health Professions · doi:10.1002/chp.21152 · Cited by 233
SEIPS 101 and seven simple SEIPS tools
Holden, R. J., & Carayon, P. (2021) · BMJ Quality & Safety · doi:10.1136/bmjqs-2020-012538 · Cited by 231
Self-citationAn analysis of electronic health record-related patient safety concerns
Meeks, D. W., Smith, M. W., Taylor, L., Sittig, D. F., Scott, J. M., & Singh, H. (2014) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2013-002578 · Cited by 207
Self-citationSingh, H., Thomas, E. J., Mani, S., Sittig, D., Arora, H., Espadas, D., Khan, M. M., & Petersen, L. A. (2009) · Archives of Internal Medicine · doi:10.1001/archinternmed.2009.263 · Cited by 212
“The impact of several factors such as time pressures, organizational characteristics, factors related to the task of processing alerts, technological factors, and HCP factors should be considered in the design of interventions to improve timely follow-up.(29,30) Future studies should address process-of-care issues lea…”
BackgroundQualitative HCI Research: Going Behind the Scenes
BLANDFORD, A. E., Furniss, D. J., & Makri, S. (2016) · Synthesis lectures on human-centered informatics · doi:10.2200/s00706ed1v01y201602hci034 · Cited by 89
Time to accelerate integration of human factors and ergonomics in patient safety: Table 1
Gürses, A. P., Ozok, A. A., & Pronovost, P. J. (2011) · BMJ Quality & Safety · doi:10.1136/bmjqs-2011-000421 · Cited by 205
“using HFE principles and methods, then healthcare processes will improve, resulting in the improvement of healthcare professionals’ performance and outcomes.(7) A straightforward example is the interaction between healthcare providers and medical devices.”
MethodSelf-citationValdez, R. S., Holden, R. J., Novak, L. L., & Veinot, T. C. (2014) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2014-002826 · Cited by 201
Framework for Patient Safety Research and Improvement
Pronovost, P. J., Goeschel, C. A., Marsteller, J. A., Sexton, J. B., Pham, J. C., & Berenholtz, S. M. (2009) · Circulation · doi:10.1161/circulationaha.107.729848 · Cited by 192
Health Care 4.0: A vision for smart and connected health care
Li, J., & Carayon, P. (2021) · IISE Transactions on Healthcare Systems Engineering · doi:10.1080/24725579.2021.1884627 · Cited by 190
“The integration illustrated in Figure 7 can benefit from an overall conceptual framework, such as the SEIPS (Systems Engineering Initiative for Patient Safety) model (Carayon et al., 2006, 2014).”
MethodSelf-citationThe 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 195
“The Systems Engineering Initiative for Patient Safety model of work system and patient safety ( Carayon, Hundt, et al, 2006 ) integrates the work system model into the well-known Structure–Process–Outcome model of quality of care by Donabedian (1978 ).”
MethodSelf-citationSafety Culture, Patient Safety, and Quality of Care Outcomes: A Literature Review
Lee, S. E., Scott, L. D., Dahinten, V. S., Vincent, C., Lopez, K. D., & Park, C. G. (2017) · Western Journal of Nursing Research · doi:10.1177/0193945917747416 · Cited by 186
Gürses, A. P., Carayon, P., & Wall, M. M. (2008) · Health Services Research · doi:10.1111/j.1475-6773.2008.00934.x · Cited by 187
Self-citationWhat Exactly Is Patient Safety?
Emanuel, L. L., Berwick, D., Conway, J., Combes, J., Hatlie, M. J., Leape, L. L., REASON, J. T., Schyve, P. M., Vincent, C. A., & Walton, M. (2009) · Journal of Medical Regulation · doi:10.30770/2572-1852-95.1.13 · Cited by 205
A systematic review of safety violations in industry
Alper, S. J., & Karsh, B. (2009) · Accident Analysis & Prevention · doi:10.1016/j.aap.2009.03.013 · Cited by 179
Self-citationNASA-TLX Assessment of Surgeon Workload Variation Across Specialties
Lowndes, B. R., Forsyth, K. L., Blocker, R. C., Dean, P. G., Truty, M. J., Heller, S. F., Blackmon, S. H., Hallbeck, M. S., & Nelson, H. (2018) · Annals of Surgery · doi:10.1097/sla.0000000000003058 · Cited by 177
Continuous glucose monitors and automated insulin dosing systems in the hospital consensus guideline
Galindo, R. J., Umpierrez, G. E., Rushakoff, R. J., Basu, A., Lohnes, S., Nichols, J. H., Spanakis, E. K., Espinoza, J., Palermo, N. E., Awadjie, D. G., et al. (2020) · Journal of Diabetes Science and Technology · doi:10.1177/1932296820954163 · Cited by 170
Status of patient safety culture in Arab countries: a systematic review
Elmontsri, M., Almashrafi, A., Banarsee, R., & Majeed, A. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-013487 · Cited by 168
“Systems that minimise the likelihood of errors while maximising the likelihood of intercepting these errors need to be established.(63) An efficient operating mechanism that is dependent on the collaboration of the subparts to achieve an outcome is what describes the system approach to patient safety.”
BackgroundDigital Twins for Managing Health Care Systems: Rapid Literature Review
Elkefi, S., & Asan, O. (2022) · Journal of Medical Internet Research · doi:10.2196/37641 · Cited by 169
Holden, R. J. (2010) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2009.12.003 · Cited by 168
“…environment of work stations and walls (i.e., connectivity), to organizational factors such as provision of technical support and other resources, to the content and timing of tasks, to technological capability and usability, to cognitive and motivational personal factors, and more [49,50].”
BackgroundHuman factors in patient safety as an innovation
Carayon, P. (2010) · Applied Ergonomics · doi:10.1016/j.apergo.2009.12.011 · Cited by 162
“They also need to understand the underlying relationships between work system factors and other HFE variables and patient safety outcomes (Carayon et al., 2007a, 2006) [recommendation R4].”
BackgroundSelf-citationSingh, H., Thomas, E. J., Sittig, D. F., Wilson, L., Espadas, D., Khan, M. M., & Petersen, L. A. (2010) · The American Journal of Medicine · doi:10.1016/j.amjmed.2009.07.027 · Cited by 160
Gürses, A. P., Seidl, K. L., Vaidya, V. U., Bochicchio, G. V., Harris, A. D., Hebden, J. N., & Xiao, Y. (2008) · BMJ Quality & Safety · doi:10.1136/qshc.2006.021709 · Cited by 154
Self-citationBritish Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy
Sidhu, R., Turnbull, D., Haboubi, H., Leeds, J., Healey, C., Hebbar, S., Collins, P., Jones, W., Peerally, M., Brogden, S., et al. (2023) · Gut · doi:10.1136/gutjnl-2023-330396 · Cited by 167
Nursing Workload and Patient Safety—A Human Factors Engineering Perspective
Carayon, P., & Gürses, A. P. (2008) · Cited by 161
Self-citationCrossing 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
“Each broader level of the system provides context for the systems nestedwithin it, and that context includes policies and procedures, norms, technologies, physical environments and people specific to that level (Carayon et al., 2006; Holden and Karsh, 2009; Karsh et al., 2006).”
BackgroundInfluentialSelf-citationPatient safety - the role of human factors and systems engineering.
Carayon, P., & Wood, K. E. (2010) · PubMed · Cited by 153
Self-citationA critical review of the systems approach within patient safety research
Waterson, P. E. (2009) · Ergonomics · doi:10.1080/00140130903042782 · Cited by 155
Gurses, A. P., Marsteller, J. A., Ozok, A. A., Xiao, Y., Owens, S., & Pronovost, P. J. (2010) · Critical Care Medicine · doi:10.1097/ccm.0b013e3181e69e02 · Cited by 145
“, workload, task ambiguity, responsibility ambiguity, method ambiguity) Cabana et al (11), PRECEDE (74), SEIPS (37), Systems ambiguity (28)”
BackgroundMethodInfluentialSelf-citationXie, A., & Carayon, P. (2014) · Ergonomics · doi:10.1080/00140139.2014.959070 · Cited by 153
“These projects, although important, do not consider complex sociotechnical system characteristics that need to be addressed to improve overall system outcomes from the viewpoint of patients, employees and organisations (Carayon et al. 2006; 2014; Hendrick 1980; Hendrick and Kleiner 2001).”
BackgroundMethodInfluentialSelf-citationPEARLS for Systems Integration
Dubé, M. M., Reid, J. R., Kaba, A., Cheng, A., Eppich, W., Grant, V. J., & Stone, K. P. (2019) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000381 · Cited by 136
Holden, R. J. (2010) · Cognition Technology & Work · doi:10.1007/s10111-010-0141-8 · Cited by 134
“eted, dynamically interacting work system (Carayon et al. 2006; Karsh et al. 2006b).”
BackgroundTucker, A. L., Singer, S. J., Hayes, J. E., & Falwell, A. (2008) · Health Services Research · doi:10.1111/j.1475-6773.2008.00868.x · Cited by 129
“Poor facility design can compromise patient confidentiality and create safety risks through limited patient visibility (Carayon et al. 2006).”
BackgroundSociotechnical systems analysis in health care: a research agenda
Carayon, P., Bass, E. J., Bellandi, T., Gürses, A. P., Hallbeck, M. S., & Mollo, V. (2011) · IIE Transactions on Healthcare Systems Engineering · doi:10.1080/19488300.2011.619158 · Cited by 139
“The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety (Carayon et al., 2006) is one example of this STSA approach aimed at understanding the complex system interactions that can produce hazards and patient safety risks.”
BackgroundMethodInfluentialSelf-citationSafety, efficiency and learning curves in robotic surgery: a human factors analysis
Catchpole, K., Perkins, C. E., Bresee, C. J., et al. (2015) · Surgical Endoscopy · doi:10.1007/s00464-015-4671-2 · Cited by 125
Nurse Health, Work Environment, Presenteeism and Patient Safety
Rainbow, J. G., Drake, D. A., & Steege, L. M. (2020) · Western Journal of Nursing Research · doi:10.1177/0193945919863409 · Cited by 123
“The model is also influenced by human factors models, particularly the Systems Engineering Initiative for Patient Safety (SEIPS) model, that suggest there are multiple individual and organizational structures that are a part of processes and outcomes in health care settings (Carayon et al., 2006).”
MethodFrom 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
Self-citationState of science: human factors and ergonomics in healthcare
Hignett, S. M., Carayon, P., Buckle, P., & Catchpole, K. C. (2013) · Ergonomics · doi:10.1080/00140139.2013.822932 · Cited by 123
“Conceptual model for ergonomics in the healthcare industry (Carayon et al. 2006).”
BackgroundMethodInfluentialSelf-citationSteege, L. M. B., & Rainbow, J. G. (2016) · International Journal of Nursing Studies · doi:10.1016/j.ijnurstu.2016.11.014 · Cited by 120
A Systematic Review of Mixed Methods Research on Human Factors and Ergonomics in Health Care
Carayon, P., Kianfar, S., Li, Y., Xie, A.-P., Alyousef, B., & Wooldridge, A. R. (2015) · Applied Ergonomics · doi:10.1016/j.apergo.2015.06.001 · Cited by 119
Self-citationExploring performance obstacles of intensive care nurses
Gürses, A. P., & Carayon, P. (2008) · Applied Ergonomics · doi:10.1016/j.apergo.2008.09.003 · Cited by 127
“For such an initiative, we recommend use of a participatory ergonomics approach (Wilson and Haines, 1997) with active involvement of ICU nurses in prioritizing, developing, implementing, and evaluating interventions that will improve their work system as well as the quality and safety of patient care (Carayon et al.,…”
BackgroundMethodInfluentialSelf-citationCooper, W. O., Guillamondegui, O. D., Hines, O. J., et al. (2017) · JAMA Surgery · doi:10.1001/jamasurg.2016.5703 · Cited by 121
ICU nurses' acceptance of electronic health records
Carayon, P., Cartmill, R. S., Blosky, M. A., Brown, R., Hackenberg, M., Hoonakker, P., Hundt, A. S., Norfolk, E. R., Wetterneck, T. B., & Walker, J. M. (2011) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2010-000018 · Cited by 122
Self-citationChui, M. A., Mott, D. A., & Maxwell, L. (2012) · Research in Social and Administrative Pharmacy · doi:10.1016/j.sapharm.2011.06.001 · Cited by 122
A review of models relevant to road safety
Hughes, B., Newstead, S., Anund, A., Shu, C. C., & Falkmer, T. (2014) · Accident Analysis & Prevention · doi:10.1016/j.aap.2014.06.003 · Cited by 136
Gürses, A. P., Kim, G., Martinez, E. A., Marsteller, J. A., Bauer, L. C., Lubomski, L. H., Pronovost, P. J., & Thompson, D. (2012) · BMJ Quality & Safety · doi:10.1136/bmjqs-2011-000625 · Cited by 120
“The top level followed the SEIPS model and included care provider, tasks, tools/technologies, organisation, physical environment and processes.(21) The second and third level categories were generated based on the data.”
MethodSelf-citationSørensen, J. L., van der Vleuten, C. P. M., Rosthøj, S., Østergaard, D., LeBlanc, V. R., Johansen, M., Ekelund, K., Starkopf, L., Lindschou, J., Gluud, C. N., et al. (2015) · BMJ Open · doi:10.1136/bmjopen-2015-008344 · Cited by 117
EHR Safety: The Way Forward to Safe and Effective Systems
Walker, J. M., Carayon, P., Leveson, N., Paulus, R. A., Tooker, J., Chin, H., Bothe, A., & Stewart, W. F. (2008) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m2618 · Cited by 113
Self-citationDeLucia, P. R., Ott, T. E., & Palmieri, P. A. (2009) · Reviews of Human Factors and Ergonomics · doi:10.1518/155723409x448008 · Cited by 120
Global food safety as a complex adaptive system: Key concepts and future prospects
Nayak, R., & Waterson, P. E. (2019) · Trends in Food Science & Technology · doi:10.1016/j.tifs.2019.07.040 · Cited by 112
Realizing Improved Patient Care through Human-centered Operating Room Design
Palmer, G., Abernathy, J. H., Swinton, G., Allison, D., Greenstein, J. S., Shappell, S. A., Juang, K. A., & Reeves, S. T. (2013) · Anesthesiology · doi:10.1097/aln.0b013e31829f68cf · Cited by 107
Carayon, P., Wooldridge, A. R., Hose, B., Salwei, M. E., & Benneyan, J. C. (2018) · Health Affairs · doi:10.1377/hlthaff.2018.0723 · Cited by 111
Self-citationResearch Trends in Artificial Intelligence Applications in Human Factors Health Care: Mapping Review
Asan, O., & Choudhury, A. (2021) · JMIR Human Factors · doi:10.2196/28236 · Cited by 114
“This framework also helps to assess and understand the complex interaction between elements of the work system, and shows the impact of any technology-based intervention on the overall system [83].”
BackgroundMethodInfluentialFactors contributing to an increase in duplicate medication order errors after CPOE implementation
Wetterneck, T. B., Walker, J. M., Blosky, M. A., Cartmill, R. S., Hoonakker, P., Johnson, M., Norfolk, E. R., & Carayon, P. (2011) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2011-000255 · Cited by 113
Self-citationUnertl, K. M., Novak, L. L., Johnson, K. B., & Lorenzi, N. M. (2010) · Journal of the American Medical Informatics Association · doi:10.1136/jamia.2010.004333 · Cited by 112
The Impact of Electronic Health Records on Diagnosis
Graber, M. L., Byrne, C., & Johnston, D. (2017) · Diagnosis · doi:10.1515/dx-2017-0012 · Cited by 108
“Ensuring that the EHR performs optimally in clinical settings requires not just optimizing the software but also consideration of all the sociotechnical factors that determine performance in using health IT applications [4, 100, 101].”
BackgroundChua, W. L., See, M. T. A., Legido‐Quigley, H., Jones, D. A., Tee, A. K. H., & Liaw, S. Y. (2017) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzx149 · Cited by 119
“themes, which were then categorized into the five interacting components of the work systems of the SEIPS model: the person[s] using various tools and technologies to perform tasks in an environment under certain organizational conditions [73].”
BackgroundMethodInfluentialSchneider, A., Wehler, M., & Weigl, M. (2019) · BMC Emergency Medicine · doi:10.1186/s12873-018-0218-x · Cited by 108
Salwei, M. E., & Carayon, P. (2022) · Journal of Cognitive Engineering and Decision Making · doi:10.1177/15553434221097357 · Cited by 112
“Early in the development of AI technologies, designers need to consider how feedback loops will be integrated in the work system to support the monitoring of the technology in real use and to help identify problems as they arise (Carayon et al., 2006, 2014).”
BackgroundSelf-citationVincent, C., Li, Y., & BLANDFORD, A. E. (2013) · Applied Ergonomics · doi:10.1016/j.apergo.2013.05.009 · Cited by 107
Guise, V., Anderson, J., & Wiig, S. (2014) · BMC Health Services Research · doi:10.1186/s12913-014-0588-z · Cited by 102
Carayon, P., Wetterneck, T. B., Cartmill, R. S., Blosky, M. A., Brown, R., Kim, R., Kukreja, S., Johnson, M., Paris, B. L., Wood, K. E., et al. (2013) · BMJ Quality & Safety · doi:10.1136/bmjqs-2013-001828 · Cited by 102
Self-citationDigital health technology enhances resilient behaviour: evidence from the ward
Rubbio, I., Bruccoleri, M., Pietrosi, A., & Ragonese, B. (2018) · International Journal of Operations & Production Management · doi:10.1108/ijopm-02-2018-0057 · Cited by 113
Olson, A., Rencic, J., Cosby, K., Rusz, D., Papa, F., Croskerry, P., Zierler, B., Harkless, G., Giuliano, M. A., Schoenbaum, S., et al. (2019) · Diagnosis · doi:10.1515/dx-2018-0107 · Cited by 101
“Second, the practice environment and health care system both have a dramatic impact on individual and team performance, and ultimately on the diagnostic process itself [12, 13].”
BackgroundKoppel, R., & Kreda, D. (2009) · JAMA · doi:10.1001/jama.2009.398 · Cited by 99
Lessons Learned From Implementing CDC’s STEADI Falls Prevention Algorithm in Primary Care
Casey, C. M., Parker, E., Winkler, G., Liu, X., Lambert, G. H., & Eckstrom, E. (2016) · The Gerontologist · doi:10.1093/geront/gnw074 · Cited by 102
“…facilitate practice change, including the plan-do-study-act (PDSA) framework, the Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al., 2006; Perry, Bell, Shaw, Fitzpatrick, & Sampson, 2014), and the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and…”
Olakotan, O. O., & Mohd Yusof, M. (2021) · Health Informatics Journal · doi:10.1177/14604582211007536 · Cited by 101
Workload and Patient Safety Among Critical Care Nurses
Carayon, P., & Alvarado, C. J. (2007) · Critical Care Nursing Clinics of North America · doi:10.1016/j.ccell.2007.02.001 · Cited by 100
Self-citationKeebler, J. R., Lazzara, E. H., Patzer, B. S., Palmer, E. M., Plummer, J. P., Smith, D. C., Lew, V., Fouquet, S., Chan, Y. R., & Riss, R. (2016) · Human Factors: The Journal of the Human Factors and Ergonomics Society · doi:10.1177/0018720816672309 · Cited by 97
“…and development of the field. theoretical Basis: the Systems Engineering in Patient Safety (SEIPS) Model We elected to adopt the SEIPS model (Carayon et al., 2006) to organize our four overarching categories of variables that are suitable for understanding the effects of protocols in…”
BackgroundMethodInfluentialMeeks, D. W., Takian, A., Sittig, D. F., Singh, H., & Barber, N. (2014) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2013-001762 · Cited by 91
Campbell, A. R., Layne, D. M., Scott, E. S., & Wei, H. (2020) · Journal of Nursing Management · doi:10.1111/jonm.13083 · Cited by 117
Holden, R. J. (2011) · Journal of Patient Safety · doi:10.1097/pts.0b013e3182388cfa · Cited by 102
SEIPS-based process modeling in primary care
Wooldridge, A. R., Carayon, P., Hundt, A. S., & Hoonakker, P. (2016) · Applied Ergonomics · doi:10.1016/j.apergo.2016.11.010 · Cited by 95
“…for Process Modeling The SEIPS model integrates human factors and healthcare models to propose a systems engineering model to understand the care process by representing all work system elements; this model provides a representation of the complexities of health care (Carayon et al., 2006).”
BackgroundMethodInfluentialSelf-citationTo err is human: use of simulation to enhance training and patient safety in anaesthesia
Higham, H., & Baxendale, B. (2017) · British Journal of Anaesthesia · doi:10.1093/bja/aex302 · Cited by 96
A scoping review of interventions for older adults transitioning from hospital to home
Liebzeit, D., Rutkowski, R. A., Arbaje, A. I., Fields, B., & Werner, N. E. (2021) · Journal of the American Geriatrics Society · doi:10.1111/jgs.17323 · Cited by 98
Safety Hazards During Intrahospital Transport: A Prospective Observational Study
Bergman, L., Pettersson, M. E., Chaboyer, W. P., et al. (2017) · Critical Care Medicine · doi:10.1097/ccm.0000000000002653 · Cited by 95
“The System Engineering Initiative for Patient Safety (SEIPS) model (26, 27), a framework for proactively improving patient safety by focusing on the design of the work system, was used to guide data analysis.”
MethodOzok, A. A., & Wei, J. C. (2010) · Electronic Commerce Research · doi:10.1007/s10660-010-9048-y · Cited by 94
Waterson, P. E. (2013) · Applied Ergonomics · doi:10.1016/j.apergo.2013.07.004 · Cited by 96
“Much of the case study data reported here for example, could have been interpreted through a large range of alternative theoretical ‘lenses’ (e.g., alternative sociotechnical models e Carayon et al., 2006; Sittig and Singh, 2010; HIT technology acceptance models e Holden and h et al., 2010).”
BackgroundImproving cardiac surgical care: A work systems approach
Wiegmann, D. A., Eggman, A. A., ElBardissi, A. W., et al. (2010) · Applied Ergonomics · doi:10.1016/j.apergo.2009.12.008 · Cited by 93
“Specifically, the Systems Engineering Initiative to Patient Safety (SEIPS) model (Carayon et al., 2006) indicates that in addition to surgical skill (person factors), performance and outcomes are also impacted by such factors as teamwork and communication, the physical working environment,…”
BackgroundPatterson, B. W., Pulia, M. S., Ravi, S., Hoonakker, P., Hundt, A. S., Wiegmann, D. A., Wirkus, E. J., Johnson, S. M., & Carayon, P. (2019) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2018.10.034 · Cited by 105
“Given the complexity of the sociotechnical systems (such as the ED) in which they are implemented, 13,14 however, clinical decision support technologies have the potential for negative consequences.”
BackgroundSelf-citationHealth care provider social network analysis: A systematic review
Bae, S., Nikolaev, A. G., Seo, J. Y., et al. (2015) · Nursing Outlook · doi:10.1016/j.outlook.2015.05.006 · Cited by 92
Patient Adherence to Dysphagia Recommendations: A Systematic Review
Krekeler, B. N., Broadfoot, C. K., Johnson, S. M., Connor, N. P., & Rogus‐Pulia, N. M. (2017) · Dysphagia · doi:10.1007/s00455-017-9852-9 · Cited by 102
Fenny, A. P., Enemark, U., Asante, F., & Hansen, K. S. (2014) · Global Journal of Health Science · doi:10.5539/gjhs.v6n4p9 · Cited by 99
Metadata
- Authors
- Carayon, P., Schoofs Hundt, A., Karsh, B.-T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P.
- Affiliations
- University of Wisconsin–Madison (US)
- Corresponding author
- Carayon, P
- ORCID
- Venue
- Quality in Health Care
- Publisher
- BMJ
- Published
- 2006-12
- Volume
- 15
- Issue
- suppl 1
- Pages
- i50-i58
- ISSN
- 1475-3898 (ISSN-L)
- 1475-3901
- PMC
- PMC2464868
- OpenAlex
- W2163767758
- Semantic Scholar
- d1341354adecf3074cdce8d706ccfec017ac370f
- Cited by
- 1,795
- References
- 53
- Citations by year
- 2026: 199 · 2025: 140 · 2024: 129 · 2023: 122 · 2022: 119 · 2021: 150 · 2020: 132 · 2019: 118 · 2018: 102 · 2017: 93 · 2016: 97 · 2015: 70 · 2014: 77 · 2013: 66 · 2012: 50
- FWCI
- 4.54
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- BMJ Quality & Safety (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Agency for Healthcare Research and Quality (#P20 HS11561-01, P20 HS011561)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Quality and Management
- Social Sciences › Human Factors and Ergonomics › Ergonomics and Human Factors
- Keywords
- work system design, patient safety, SEIPS model, health care system, outpatient surgery, safety culture
- MeSH terms
- Humans, Ergonomics, Models, Theoretical, Quality Assurance, Health Care, Surgicenters, Systems Analysis, Task Performance and Analysis, United States, Outcome Assessment, Health Care, Safety Management, Medical Errors
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.
A language model drew the claims from the paper on 2026-10-11, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-11 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
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 ›
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