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
Baker, A. (2001) · BMJ · doi:10.1136/bmj.323.7322.1192 · Cited by 10,779
To Err is Human: Building a Safer Health System
Hendee, W. R. (2001) · Journal of Vascular and Interventional Radiology · doi:10.1016/s1051-0443(01)70072-3 · Cited by 10,129
Crossing the Quality Chasm: A New Health System for the 21st Century
Committee on Quality of Health Care in America (2002) · Journal for Healthcare Quality · doi:10.1111/j.1945-1474.2002.tb00463.x · Cited by 8,508
Evaluating the quality of medical care
DONABEDIAN, A. (2005) · The Milbank Quarterly · doi:10.1111/j.1468-0009.2005.00397.x · Cited by 6,102
Donabedian, A. (1988) · JAMA · doi:10.1001/jama.260.12.1743 · Cited by 5,895
Evaluating the Quality of Medical Care
Donabedian, A. (1966) · The Milbank Memorial Fund Quarterly · doi:10.2307/3348969 · Cited by 4,418
Profession of Medicine: A Study of the Sociology of Applied Knowledge.
Clausen, G. T., & Freidson, E. (1971) · American Sociological Review · doi:10.2307/2093843 · Cited by 2,047
Leape, L. L. (1994) · PubMed · Cited by 1,961
The definition of quality and approaches to its assessment
Donabedian, A. (1980) · Health Administration Press eBooks · Cited by 1,749
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Cited by
Sorted by citations
Items 901–1,000 of 1,789
McKnight, J., Willows, T. M., Oliwa, J. N., et al. (2023) · Journal of Global Health · doi:10.7189/jogh.13.04139 · Cited by 5
“This is particularly the case as we saw no need to iterate or move beyond the categories of issues established as part of the SEIPS framework [37].”
BackgroundExperiences of Alert Fatigue and Its Contributing Factors in Hospitals: Qualitative Study
Newton, N., Bamgboje‐Ayodele, A., Forsyth, R., Tariq, A., Huang, J., Yannam, R., Lalor, D. J., Sobey, A. J., & Baysari, M. T. (2025) · Journal of Medical Internet Research · doi:10.2196/78676 · Cited by 12
“The Systems Engineering Initiative for Patient Safety (SEIPS) is a human factors model used in health care settings to identify and address safety concerns [24].”
Jimenez, Y. A., Hill, S. R., Lewis, S. J., et al. (2023) · Radiography · doi:10.1016/j.radi.2023.11.014 · Cited by 5
Enhanced Teamwork Communication Model for Electronic Clinical Pathways in Healthcare
Mater, W., Aldwairi, M., & Ibrahim, R. B. (2018) · The Open Bioinformatics Journal · doi:10.2174/1875036201811010140 · Cited by 6
“The Donabedian model tries to address the question, ‘what is quality in medical care [77].”
BackgroundMethodSociotechnical Issues of Tele-ICU Technology
Hoonakker, P., McGuire, K., & Carayon, P. (2011) · IGI Global eBooks · doi:10.4018/978-1-60960-057-0.ch018 · Cited by 5
Self-citationA review of human factors and infusion pumps: lessons for procurement
Herrero, L., Cano, M., Ratwani, R. M., Sánchez, L., Sánchez, B., Sancibrián, R., & Peralta, G. (2025) · Frontiers in Digital Health · doi:10.3389/fdgth.2025.1425409 · Cited by 5
Wahr, J. A., & Abernathy, J. H. (2014) · Current anesthesiology reports · doi:10.1007/s40140-014-0052-y · Cited by 5
“Table 1 The ten step process to promoting a culture of safety [61]”
BackgroundMethodInfluentialHuman factors paradigm and customer care perceptions
Clarke, C., & Eales‐Reynolds, L. (2015) · International Journal of Health Care Quality Assurance · doi:10.1108/ijhcqa-05-2014-0067 · Cited by 5
Integrated therapy safety management system
Podtschaske, B. V., Fuchs, D., & Friesdorf, W. (2013) · British Journal of Clinical Pharmacology · doi:10.1111/bcp.12155 · Cited by 5
Perspectives on Airway Protection: A Mixed Methods Investigation in People With Parkinson's Disease
Sevitz, J. S., Rogus‐Pulia, N. M., & Troche, M. S. (2025) · American Journal of Speech-Language Pathology · doi:10.1044/2024_ajslp-24-00353 · Cited by 5
Joshi, H., Joseph, S., & Shukla, P. S. (2024) · Advances in medical technologies and clinical practice book series · doi:10.4018/979-8-3693-5893-1.ch016 · Cited by 5
Lifestyles in Later Life: identity, choice and stigma
Hamblin, K. A. (2014) · Cited by 5
Understanding and responding when things go wrong: key principles for primary care educators
McNab, D., Bowie, P., Ross, A. J., et al. (2016) · Education for Primary Care · doi:10.1080/14739879.2016.1205959 · Cited by 5
Jabin, M. S. R. (2026) · Frontiers in Digital Health · doi:10.3389/fdgth.2026.1786358 · Cited by 6
Designing and implementing exoskeleton devices for nurses with acute and chronic pain
Scheer, E. R., Atweh, J. A., Arora, J., Thompson, E., Petty, L., Huh, R. J., Murray, J., Sellers, E., Srinivasan, D., & Valdez, R. S. (2025) · Applied Ergonomics · doi:10.1016/j.apergo.2025.104596 · Cited by 5
Oh, S., Sang, E., Stawnychy, M. A., Garren, P. A., You, S. B., O’Connor, M. L., Hirschman, K. B., Hodgson, N. A., Cranston, T., Jablonski, J., et al. (2024) · Human Factors The Journal of the Human Factors and Ergonomics Society · doi:10.1177/00187208231222399 · Cited by 6
“However, during the subsequent process mapping, SEIPS work system elements were identi fi ed from the implementation determinants by SO (Carayon et al., 2006), veri fi ed by a second coder (KHB), and member-checked by the clinicians (TC, JJ, KO, MN, MS) involved in this study to ensure credibility…”
InfluentialKalteh, H. O., & Mokarami, H. (2021) · International Journal of Occupational Safety and Ergonomics · doi:10.1080/10803548.2021.1996070 · Cited by 5
Taking a Resilience Engineering Approach to Perioperative Handoffs
Samost, A., Lusk, C., & Catchpole, K. C. (2023) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2023.03.010 · Cited by 5
Asan, O., Choudhury, A., Somai, M. M., & Crotty, B. H. (2020) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2020.104345 · Cited by 5
Evaluation of Medication Administration Process: Tools and Techniques
Snyder, R. A., Huynh, N., Cai, B., et al. (2011) · Journal of Healthcare Engineering · doi:10.1260/2040-2295.2.4.527 · Cited by 5
“medication errors are precipitated by fragmented and highly complex medication management processes [5].”
BackgroundWolf, L., Parker, S. H., & Gleason, J. L. (2020) · Springer eBooks · doi:10.1007/978-3-030-55829-1_20 · Cited by 5
Kobayashi, L., Boss, R. M., Gibbs, F. J., Goldlust, E. J., Hennedy, M. M., Monti, J. E., & Siegel, N. A. (2011) · HERD Health Environments Research & Design Journal · doi:10.1177/193758671100400406 · Cited by 5
Clinical and infrastructure risk management in an emergency hospital unit in Iași, Romania
Paduraru, C. Ș., Păduraru, O., Costescu, E., et al. (2025) · Balneo and PRM Research Journal · doi:10.12680/balneo.2025.834 · Cited by 5
Chen, T., Guo, J., Xie, Z., & Or, C. K. (2023) · International Journal of Industrial Ergonomics · doi:10.1016/j.ergon.2023.103453 · Cited by 5
Shankar, R. (2026) · SAGE Open Nursing · doi:10.1177/23779608261457722 · Cited by 6
“This distributed model aligns with systems-theoretic approaches to patient safety, which identify adverse events as emergent from interactions across organisational, technological, and human factors rather than from individual failure alone (Carayon et al., 2006).”
Dobrowolska, M., Flakus, M., Ślazyk-Sobol, M., & Wawoczny, A. (2020) · Sustainability · doi:10.3390/su12176843 · Cited by 8
“policy in the field of human resource management provide chances for the sustainable development of the company [42,43].”
BackgroundAssessing Unwanted Variations in Rheumatology Clinic Previsit Rooming
Ramly, E., Stroik, B., Lauver, D., Johnson, H. M., McBride, P. E., Lewicki, K., Arnason, J., & Bartels, C. M. (2018) · JCR Journal of Clinical Rheumatology · doi:10.1097/rhu.0000000000000795 · Cited by 5
Prediction of nursing burnout—a scoping review of the literature from 1970 to 2021
Leite, C. C. M., & Wooldridge, A. R. (2022) · IISE Transactions on Healthcare Systems Engineering · doi:10.1080/24725579.2022.2149638 · Cited by 7
“Systems approaches to patient safety, such as the Systems Engineering Initiative for Patient Safety (SEIPS; Carayon et al., 2006; Carayon et al., 2014; Carayon et al., 2020) are useful to improve patient safety and quality by considering the design of the sociotechnical system.”
BackgroundResidents' Insights and Ideas about Screen-Sharing in Primary Care Clinics
Fletcher, K. E., Asan, O., & Tyszka, J. T. (2017) · Applied Clinical Informatics · doi:10.4338/aci-17-0057-ra · Cited by 5
de Vries, M., Fan, M., Tscheng, D. Z., et al. (2023) · Journal of Patient Safety and Risk Management · doi:10.1177/25160435231174309 · Cited by 5
“, person, tool/ technology, organization, environment, and task) and describes their interactions.(16) Characterizing diversion vulnerabilities using the SEIPS framework will strengthen our understanding of the system factors at play and align interventions to those specific system factors.”
BackgroundInfluentialHuman Factors and Systems Engineering: The Future of Infection Prevention?
Patel, P. R., & Kallen, A. J. (2018) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2018.122 · Cited by 5
“This approach considers multiple broad outcomes simultaneously and assumes that staff engagement and job satisfaction are integrally linked to positive organizational outcomes (ie, recognition and profitability) and health and safety outcomes such as healthcare-associated infections (HAIs).(5) The idea that improvemen…”
BackgroundErgonomics in Healthcare and Patient Safety
(2014) · Journal of Ergonomics · doi:10.4172/2165-7556.1000e126 · Cited by 5
“A number of ergonomics and human factors approaches have been proposed to describe more comprehensive systems of patient safety and injury prevention such as the systems approach proposed by Vincent and colleagues [5] and the systems engineering initiative for patient safety model of work system and patient safety pro…”
BackgroundGifford, A., Butcher, B., Chima, R. S., et al. (2023) · Journal of Hospital Medicine · doi:10.1002/jhm.13216 · Cited by 5
“5 The Live Well team employed a human ‐ centered design approach, engaging in situation awareness scenario planning, which involved discussing triggers for high ‐ risk patient surveillance, reviewing order writing and executing processes for high ‐ risk patients, and viewing established educational…”
Context Sensitive Health Informatics: The Role of Informatics in Global Pandemics
Online, C. S. H. I. (. C. 2., Marcilly, R., Peute, L., Kuziemsky, C. E., Xinxin, Z., Elkin, P. L., & Nøhr, C. G. (2021) · Studies in health technology and informatics · doi:10.3233/shti286 · Cited by 5
McCormack, C. M., Savoy, A., Mathew, A., Gilmore, A. M., Cottingham, E. M., Sangani, A., Caldwell, B. S., Holden, R. J., & Weiner, M. (2023) · Applied Ergonomics · doi:10.1016/j.apergo.2023.104177 · Cited by 7
Work system barriers and facilitators of a team health information technology
Hose, B., Carayon, P., Hoonakker, P., Brazelton, T., Dean, S. M., Eithun, B. L., Kelly, M. M., Kohler, J. E., Ross, J., & Rusy, D. A. (2023) · Applied Ergonomics · doi:10.1016/j.apergo.2023.104105 · Cited by 5
Self-citationCastilho, A., Parreira, P., & Pereira, M. S. (2017) · Revista Ibero-Americana de Saúde e Envelhecimento · doi:10.24902/r.riase.2016.2(2).600 · Cited by 5
A sociotechnical systems approach toward tailored design for personal health information management
Werner, N. E., Tong, M., Nathan-Roberts, D., Smith, C. A., Tredinnick, R. D., Ponto, K., Melles, M., & Hoonakker, P. (2020) · Patient Experience Journal · doi:10.35680/2372-0247.1411 · Cited by 5
Faiola, A. J., Belkacem, I., Bergey, D. E., et al. (2019) · Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care · doi:10.1177/2327857919081012 · Cited by 5
“Because ICU patients are fragile and extremely vulnerable to changes in their health condition, their safety is a priority for ICU staff ( Carayon et al., 2006) .”
BackgroundStepwise development of a quality assessment instrument for the medicines’ pathway in nursing homes
Damiaens, A., Strauven, G., Lepeleire, J. D., et al. (2023) · Research in Social and Administrative Pharmacy · doi:10.1016/j.sapharm.2023.07.008 · Cited by 5
RETOS DE LA EDUCACIÓN EN LA NUEVA REALIDAD
y Tecnología, U. I. D. C., & López, I. C. H. (2021) · doi:10.47300/978-9962-5599-8-6-04 · Cited by 5
Adverse Event Investigation and Risk Assessment
Bellandi, T., Romani-Vidal, A., Sousa, P. J. D. S., et al. (2020) · Springer eBooks · doi:10.1007/978-3-030-59403-9_11 · Cited by 5
Ramly, E., Lauver, D., Gilmore‐Bykovskyi, A. L., & Bartels, C. M. (2021) · Implementation Science Communications · doi:10.1186/s43058-021-00155-4 · Cited by 7
“Questionnaires developed by the study team included items to evaluate acceptability and fidelity to theory components [19, 20, 22, 25, 26] and support for the work system [37, 38].”
MethodAbebe, E., Scanlon, M. C., Chen, H., & Yu, D. (2020) · Hospital Pediatrics · doi:10.1542/hpeds.2020-0080 · Cited by 5
Baartmans, M. C., Schoten, S. M. V., Smit, B. J., et al. (2023) · Journal of Patient Safety · doi:10.1097/pts.0000000000001104 · Cited by 5
Zare, R., Kazemi, R., Choobineh, A., Cousins, R., Smith, A. P., & Mokarami, H. (2024) · Heliyon · doi:10.1016/j.heliyon.2024.e40226 · Cited by 5
“This can be understood in terms of work system overloads leading to job stress and, if allowed to continue, job burnout in employees [10,11].”
Status of Occupational Health and Safety in Nepal: Current Scenario and Strategies for Improvement
Prajapati, R., Dahal, A., Khanal, A., et al. (2023) · Journal of Multidisciplinary Research Advancements · doi:10.3126/jomra.v1i2.61194 · Cited by 5
Ferrand, Y., Fredendall, L. D., Siemens, J. C., et al. (2022) · Quality Management Journal · doi:10.1080/10686967.2022.2083037 · Cited by 5
“Another widely used framework is the human factors perspective of the Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al. 2006).”
MethodTowards a safer healthcare system
Henriksen, K., & Albolino, S. (2010) · BMJ Quality & Safety · doi:10.1136/qshc.2010.045849 · Cited by 6
Ahmed, A., Khan, H. T. A., & Lawal, M. (2022) · Healthcare · doi:10.3390/healthcare10071268 · Cited by 5
Lachman, P. I., Gondek, D., Edbrooke-Childs, J. H., Deighton, J., & Stapley, E. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-042163 · Cited by 5
Digital Health and Healthcare Quality: A Primer on the Evolving 4th Industrial Revolution
Otokiti, A. U. (2020) · IntechOpen eBooks · doi:10.5772/intechopen.94054 · Cited by 5
Or, C. K., Valdez, R. S., Casper, G. R., Carayon, P., Burke, L. J., Brennan, P. F., & Karsh, B. (2008) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/154193120805201219 · Cited by 5
“The analysis follows the five elements of a work system according to the work system model: technologies/tools, people, environment, organization, tasks (Carayon et al., 2006).”
MethodSelf-citationAbebe, E., & Chui, M. A. (2018) · INNOVATIONS in pharmacy · doi:10.24926/iip.v9i1.950 · Cited by 5
Baek, H., & Han, K. (2024) · Heliyon · doi:10.1016/j.heliyon.2024.e34450 · Cited by 5
“The complex interrelationships among these elements generate psychosocial, cognitive, and physical loads on the individual, and these interactions significantly influence work performance and patient and worker health [9,10].”
BackgroundMethodConceptualizing Sociotechnical System Boundaries in Healthcare Settings
Xie, A., Gürses, A. P., Hundt, A. S., Steege, L. M. B., Valdez, R. S., & Werner, N. E. (2016) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931213601198 · Cited by 5
“A macroergonomic approach that accounts for all components of the work system, such as the Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al., 2006) is therefore warranted in addressing nurse fatigue.”
BackgroundMethodSelf-citationWani, T. A., Mendoza, A., & Gray, K. M. (2025) · JMIR Human Factors · doi:10.2196/71912 · Cited by 6
“The complexity of health care systems, characterized by intricate interactions between technology, clinical workflows, communication, and regulatory requirements, necessitates a maturity model that encompasses both technical and sociotechnical dimensions [37-39].”
Human Factors Engineering: Targeting Systems for Change
Sesto, M. E., Tevaarwerk, A. J., & Wiegmann, D. A. (2011) · Springer eBooks · doi:10.1007/978-1-4419-1348-7_16 · Cited by 5
“For example, the Systems Engineering Initiative to Patient Safety (SEIPS) model [ 30 ] (Fig. 16.1), a commonly used HFE model, indicates that understanding why errors occur, and how they can be prevented, requires the consideration of the entire organizational system in which health care is provided.”
MethodInfluentialBarbieri, D. F., Srinivasan, D., Ulrich, J., Ranganathan, S., Chang, C. K., Gerac, J., & Cha, J. S. (2025) · Human Factors in Healthcare · doi:10.1016/j.hfh.2025.100098 · Cited by 5
Sociotechnical system design to support disaster intervention development teams
Hale-Lopez, K. L., Goldstein, M. H., & Wooldridge, A. R. (2023) · Applied Ergonomics · doi:10.1016/j.apergo.2022.103948 · Cited by 6
Proactive, Transdisciplinary Safer-System Redesign. A Field Report from the Hospital Frontline
Podtschaske, B. V., Salazar, N., & Rao, M. B. (2018) · IISE Transactions on Occupational Ergonomics and Human Factors · doi:10.1080/24725838.2018.1450794 · Cited by 4
“Although solutions to complex problems seen in healthcare require a systems approach (Carayon, 2006; Carayon et al., 2006; Donchin & Gopher, 2013; Kleiner et al., 2015; Vincent & Amalberti, 2016), little is known on how to adapt existing methods and tools to design resilient systems in a practical manner (Amir & Kant,…”
BackgroundMethodInfluentialPatient-Oriented Workflow Approach
Ozkaynak, M., Ponnala, S., & Werner, N. E. (2019) · Health informatics · doi:10.1007/978-3-030-16916-9_9 · Cited by 6
A sociotechnical framework for integration of telehealth into clinical workflow
Olivencia, S. B., & Sasangohar, F. (2023) · IISE Transactions on Healthcare Systems Engineering · doi:10.1080/24725579.2023.2211083 · Cited by 6
“Conceptual mapping of the workflows (e.g. Carayon et al., 2006; Salwei et al., 2021) may serve as a “big picture” view of the system and could help stakeholders characterize each of the elements included in this component.”
BackgroundMethodInfluentialGordon, M. A. (2014) · University of Salford Institutional Repository (University of Salford) · Cited by 4
Performance improvement in surgery
Alban, R. F., Anania, E. C., Cohen, T., Fabri, P. J., Gewertz, B. L., Jain, M., Jopling, J. K., Maggio, P. M., Sánchez, J. A., & Sax, H. C. (2019) · Current Problems in Surgery · doi:10.1067/j.cpsurg.2019.02.002 · Cited by 5
Berian, J. R., Schwarze, M. L., Werner, N. E., Mahoney, J., & Shah, M. N. (2024) · JMIR Research Protocols · doi:10.2196/59428 · Cited by 4
“We will use a human factors engineering model: the systems engineering initiative for patient safety (SEIPS) model [48].”
InfluentialBEGICHEVA, S. V. (2020) · IEEE International Conference on Application of Information and Communication Technologies (AICT) · doi:10.1109/aict50176.2020.9368653 · Cited by 4
“[13] suggest adding the following components to the category of structure: physical environment, organizational culture and climate, error reporting, and analysis, etc.”
BackgroundChen, K., Yen, T. Y., Sun, W., Tevaarwerk, A. J., Wiegmann, D. A., Heidrich, S. M., & Sesto, M. E. (2021) · Journal of Cancer Education · doi:10.1007/s13187-021-02048-5 · Cited by 4
Human Factors and Prevention of Medical Errors
Jalali, M. (2025) · IntechOpen eBooks · doi:10.5772/intechopen.1008399 · Cited by 7
Kelly, S. A., Lamé, G., Dixon‐Woods, M., Liberati, E. G., Kyriacou, H., Dunn, H., Egerton, A., Kok, Z. Q., Jones, K., Zheng, X. N., et al. (2024) · BMJ Open · doi:10.1136/bmjopen-2024-085827 · Cited by 6
Or, C. K., Wong, K., Tong, E., et al. (2011) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1071181311551137 · Cited by 4
“Based on the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety (Carayon et al., 2006; also see Or et al., 2009), developed at the University of Wisconsin-Madison, our field study focused on interactions among the individuals (i.e., health care…”
MethodVincent, C. A., & Amalberti, R. (2016) · Springer eBooks · doi:10.1007/978-3-319-25559-0_6 · Cited by 5
Assessment of Performance Obstacles as Perceived by Nurses in Intensive Care Units.
Ragab, S. A., Torky, M. A. M. A., & Ghallab, S. A. (2017) · Assiut Scientific Nursing Journal · doi:10.21608/asnj.2017.60616 · Cited by 4
“Figure (2) number of patients assigned to nurse during shift as perceived by the studied nurses”
BackgroundInfluentialPerera, G., Hey, L. A., Chen, K., Morello, M., McConnell, B. M., & Ivy, J. S. (2022) · Applied Ergonomics · doi:10.1016/j.apergo.2022.103786 · Cited by 4
McKinley, L. L., Goedken, C. C., Balkenende, E., et al. (2023) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2023.226 · Cited by 4
SAĞLIK KURUMLARINDA SİSTEM KAYNAKLI TIBBİ HATALARIN BAZI MODELLERLE AÇIKLANMASI
Aydemir, İ. (2018) · Dokuz Eylül Üniversitesi Sosyal Bilimler Enstitüsü Dergisi · doi:10.16953/deusosbil.281328 · Cited by 4
Li, R., Muthu, N., Hernandez‐Boussard, T., Dash, D., & Shah, N. H. (2022) · Cognitive informatics in biomedicine and healthcare · doi:10.1007/978-3-031-09108-7_8 · Cited by 4
Primary Care Patients’ and Staff’s Perceptions of Self-Rooming as Alternative to Waiting Rooms
Ramly, E., Kamnetz, S. A., Perry, C. E., Micek, M. A., Arndt, B. G., Lochner, J., Davis, S., Trowbridge, E. R., & Smith, M. A. (2023) · The Annals of Family Medicine · doi:10.1370/afm.2909 · Cited by 4
Self-citationA Macroergonomic Compatibility Index for Manufacturing Work Systems
Realyvásquez-Vargas, A., Maldonado-Macías, A. A., & García-Alcaráz, J. L. (2017) · Management and industrial engineering · doi:10.1007/978-3-319-68684-4_12 · Cited by 4
International Symposium on Occupational Safety and Hygiene: Proceedings Book of the SHO2017
Arezes, P., Baptista, J., Barroso, M., Carneiro, P., Cordeiro, P., Costa, N., Melo, R. B. M. M., Miguel, A., & Perestrelo, G. (2017) · doi:10.24840/978-989-98203-7-1 · Cited by 4
Addressing adverse events in health care through a safety science lens
Howe, J. L., Butler, R. L., Kim, T. C., & Kellogg, K. M. (2019) · Elsevier eBooks · doi:10.1016/b978-0-12-813467-2.00124-3 · Cited by 4
The Internet of Things and Opportunities for Pervasive Safety Monitored Health Environments
Michell, V. A. (2014) · Advances in healthcare information systems and administration book series · doi:10.4018/978-1-4666-4546-2.ch020 · Cited by 4
Dashboarding to Monitor Machine-Learning-Based Clinical Decision Support Interventions
Hekman, D. J., Barton, H. J., Maru, A., Wills, G. J., Cochran, A. L., Fritsch, C., Wiegmann, D. A., Liao, F., & Patterson, B. W. (2023) · Applied Clinical Informatics · doi:10.1055/a-2219-5175 · Cited by 5
“41,42 Equally importantly, we were able to quickly and easily ensure that the system was con fi gured correctly by using control charts to identify and follow up on large deviations from expected results.”
BackgroundOPERATING ROOM AND PATIENT SAFETY: AN OVERVIEW
EL-SAYED, W. M. A., ELDEEB, I. E. M. M., KHATER, M., et al. (2021) · Journal of the Egyptian Society of Parasitology · doi:10.21608/jesp.2021.193325 · Cited by 4
Duplicate Medication Order Errors: Safety Gaps and Recommendations for Improvement
Bocknek, L. S., Kim, T., Spaar, P. A., et al. (2022) · Patient Safety · doi:10.33940/data/2022.9.6 · Cited by 4
Design and Evaluation of Human-Centered Visualization Interfaces in Construction Teleoperation
Chae, Y., Gupta, S., & Ham, Y. (2024) · ASCE Construction Research Congress (CRC) · doi:10.1061/9780784485262.012 · Cited by 4
Zhang, S., & Gu, X. (2024) · BMJ Leader · doi:10.1136/leader-2024-001041 · Cited by 4
“Carayon et al 16 argue that the discipline of human factors emphasises the interaction between humans and their environment, which contributes to performance, safety and health, quality of work life and the services provided.”
Implementation of the VA Intensive Dysphagia Treatment Program: A Mixed-Methods Evaluation
Yee, J. P., Pulia, M. S., Knobloch, M. J., Martínez, R. N., Daggett, S. M., Smith, B., Musson, N. D., & Rogus‐Pulia, N. M. (2022) · Health Services Insights · doi:10.1177/11786329221121207 · Cited by 4
Reuland, C. J., Shi, G., Deatras, M., Ang, M., Evangelista, P. P. G., & Shilkofski, N. A. (2023) · Frontiers in Pediatrics · doi:10.3389/fped.2023.1127752 · Cited by 4
Freeman, W. (2012) · Cited by 4
Introductory Chapter: Patient Safety is the Cornerstone of Modern Health-Care Delivery Systems
Stawicki, S. P., Green, A. M., Lu, G. G., Domer, G. S., Oskin, T., & Firstenberg, M. S. (2019) · IntechOpen eBooks · doi:10.5772/intechopen.83842 · Cited by 4
“The success of patient safety initiatives and corresponding systemic implementations is heavily dependent on the thorough understanding of the overall framework within which structures, processes, and outcomes dynamically interact in health-care [27].”
BackgroundHow crises work: A model of error cause and effect in surgical practice
Gogălniceanu, P., Karydis, N., Kessaris, N., Olsburgh, J., Calder, F., Sevdalis, N., & Mamode, N. (2022) · International Journal of Surgery · doi:10.1016/j.ijsu.2022.106711 · Cited by 4
Bonaconsa, C., Charani, E., van den Bergh, D., Joubert, I., & Mendelson, M. (2025) · Journal of Critical Care · doi:10.1016/j.jcrc.2025.155127 · Cited by 6
Linda, M., Kelsey, B., Rosie, B., Mark, F., Keating Julie, A., & Nasia, S. (2022) · American Journal of Infection Control · doi:10.1016/j.ajic.2021.10.012 · Cited by 4
Human factors and systems engineering in critical care medicine: A scoping review
Wang, D., Qiu, Y., ZEC, S. N., Zambrano, C. C., Brown, M., Rovati, L., Hieu, T. H., & Dong, Y. (2025) · Journal of Critical Care · doi:10.1016/j.jcrc.2025.155248 · Cited by 4
Marsall, M., Schneider, A., Wehler, M., & Weigl, M. (2025) · Journal of Patient Safety and Risk Management · doi:10.1177/25160435251346900 · Cited by 4
“23 Hence, understanding interactions between system factors provides essential insights into how to improve safety and design modern clinical workplaces.”
Roberts, K., Thom, O., Hocking, J., Bernard, A., & Doyle, T. (2022) · BMJ Open Quality · doi:10.1136/bmjoq-2021-001785 · Cited by 4
Stahl, J., Hauser, C., Simon, M., Valenta, S., Favez, L., & Zúñiga, F. (2023) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2023.02.010 · Cited by 4
Exploring Work System Adaptations in Providing Care for Children with Medical Complexity in the Home
Barton, H. J., Loganathar, P., Singhe, N., et al. (2020) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1071181320641156 · Cited by 4
“It is well understood that system components interact to produce outcomes that feed back to the work system, and that feedback serves to modify the work system itself (Carayon et al., 2006; Holden et al., 2013).”
Background
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
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