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
Research works printed but not linked: 2
- [8]8. Reason J. Human error. Cambridge: Cambridge University Press, 1990.
- [31]31. Sauter S, Lim SY, Murphy LR. Organizational health: a new paradigm for occupational stress at NIOSH (in Japanese). Japanese J Occup Mental Health 1996;4:248-54.
Cited by
Sorted by citations
Items 1,101–1,200 of 1,789
Innovation and Quality Improvement: Safe or Sabotage in Nursing Homes?
Levy, C. R., Au, D. H., & Ozkaynak, M. (2021) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2021.06.026 · Cited by 3
Bamgboje‐Ayodele, A., Boscolo, A., Burger, M., et al. (2024) · Journal of Medical Internet Research · doi:10.2196/57847 · Cited by 3
“Furthermore, it is imperative for organizations to analyze existing and proposed processes (eg, co-design process) systematically at the organizational level as health IT implementations inevitably lead to new work and redistribution of existing work [35,36].”
Kabwama, S. N., Wanyenze, R. K., Razaz, N., Ssenkusu, J. M., Alfvén, T., & Lindgren, H. E. (2024) · Global Health Action · doi:10.1080/16549716.2024.2314345 · Cited by 2
“The interview guide was developed following the Systems Engineering Initiative for Patient Safety [18] which combines the work system model [19] and Donabenian’s quality of health care model [20] and covers both the demand and supply side of health care provision.”
MethodThe Business Case for Simulation-based Hospital Design Testing; $90M Saved in Costs Avoided
Colman, N., Chelette, C., Woodward, J., et al. (2024) · Pediatric Quality and Safety · doi:10.1097/pq9.0000000000000775 · Cited by 3
Defining and measuring quality in acute paediatric trauma stabilisation: a phenomenographic study
MACKINNON, R. J., Härenstam, K. P., Schwarz, U. V. T., Kennedy, C. S., & Stenfors, T. (2019) · Advances in Simulation · doi:10.1186/s41077-019-0091-z · Cited by 3
A Proactive Risk Assessment Framework to Enhance Patient Safety in Operating Rooms
Tabibzadeh, M., & Jahangiri, G. (2017) · Advances in intelligent systems and computing · doi:10.1007/978-3-319-60483-1_26 · Cited by 3
Høyland, S. A., Holte, K. A., Øygarden, O., Islam, M. K., Kjerstad, E., Gjerstad-Sørensen, R., Høyland, S. A., Wærnes, H. R., Carayon, P., Fallon, M., et al. (2024) · JMIR Research Protocols · doi:10.2196/55502 · Cited by 3
“Anchored within the STS tradition is the SEIPS framework, illustrated in Figure 1, which applies a whole system perspective on health care [36].”
BackgroundMethodSelf-citationForty years of Organisational Design and Management (ODAM)
Waterson, P. E., & Robertson, M. M. (2022) · Ergonomics · doi:10.1080/00140139.2022.2037299 · Cited by 3
“…Systems Engineering Initiative for Patient Safety (SEIPS) model for example, is widely used by researchers and practitioners in healthcare and has proved very successful in spreading the values of ODAM amongst clinicians and healthcare professionals (Carayon et al. 2006; Holden and Carayon 2021).”
MethodThompson, S., Williams, H., Rzewnicki, D. I., et al. (2024) · Applied Clinical Informatics · doi:10.1055/a-2351-9642 · Cited by 3
“9,10 We combined Lean and Function Resonance Analysis Method (FRAM) to understand the blood product ordering and administration, the results of which were presented previously.”
Translating Knowledge into Practice: Passing the Hot Potato!
Staggers, N., & BRENNAN, P. F. (2007) · Journal of the American Medical Informatics Association · doi:10.1197/j.jamia.m2529 · Cited by 3
Self-citationFields, B., Werner, N. E., Shah, M. N., Hetzel, S., Golden, B. P., Gilmore‐Bykovskyi, A. L., & Edwards, D. F. (2023) · JMIR Research Protocols · doi:10.2196/46808 · Cited by 3
“This model emphasizes a working system that includes interacting components (ie, people, tasks, tools or technology, organization, and physical environment) that influence health care processes and outcomes [22-24].”
Pop-Vicas, A. E., Keating, J. A., Heise, C. P., et al. (2020) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2020.1322 · Cited by 3
Self-citationChizallet, M., Prost, L., & Barcellini, F. (2021) · Lecture notes in networks and systems · doi:10.1007/978-3-030-74602-5_14 · Cited by 3
Whitaker, M., Lester, C. A., & Rowell, B. E. (2024) · Journal of Patient Safety · doi:10.1097/pts.0000000000001244 · Cited by 3
Elkefi, S., Asan, O., & Crotty, B. H. (2023) · IISE Transactions on Healthcare Systems Engineering · doi:10.1080/24725579.2023.2177780 · Cited by 4
“…the system components (staff, technology, tools, tasks, etc.) that cause clinical errors and failures, illustrating how the interaction between the system components can influence the acceptability of the processes based on the design of the elements and their interactions (Carayon et al., 2006).”
BackgroundHuman Factors Principles of Surgery
Cohen, T., Ley, E. J., & Gewertz, B. L. (2020) · Springer eBooks · doi:10.1007/978-3-030-53127-0_2 · Cited by 2
Brady, G., Clark, S. E., Wagstaff, D., et al. (2025) · Perioperative Care and Operating Room Management · doi:10.1016/j.pcorm.2025.100477 · Cited by 2
Alert fatigue by other names : review of contributing fields regarding the 'cry wolf' effect
Kordek, M. E. (2013) · doi:10.6083/m4dn4336 · Cited by 2
A theory-based problem-solving approach to recruitment challenges in a large randomized field trial
KOSSMAN, S. P., Hsieh, Y. G., Peace, J., et al. (2009) · Applied Nursing Research · doi:10.1016/j.apnr.2009.06.006 · Cited by 2
“Woodbridge, and Smith (2004)”
Self-citationLeeman, K. T., Raju, R. M., O’Brien, C. E., et al. (2022) · Pediatric Research · doi:10.1038/s41390-022-02097-6 · Cited by 2
“Conceptual frameworks, including the Systems Engineering Initiative for Patient Safety model, can help teams understand the complex interactions between human factors including interactions between systems, processes, and outcomes.(8,9) Decision support tools have been shown to improve compliance with NRP algorithms.”
BackgroundThe Ten Characteristics of the Critical Task
Patesson, R., & Brangier, É. (2016) · Lecture notes in computer science · doi:10.1007/978-3-319-40247-5_5 · Cited by 4
Predicting Surgical Flow Disruption Recovery in Cardiothoracic Operating Rooms
Palmer, G. (2013) · TigerPrints (Clemson University) · Cited by 2
Tabibzadeh, M., & Jahangiri, G. (2020) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1071181320641152 · Cited by 2
“Some of the previous studies on proactive risk assessment primarily focus on hazards – or “risk factors” that increase the probability of errors or injuries in healthcare settings (e.g. Carayon et al., 2006; Carayon et al., 2014; Karnon et al., 2007; Wooldridge et al., 2017).”
BackgroundŞen, H. (2025) · Türk tıp dergisi. · doi:10.70852/tmj.1736096 · Cited by 2
Design approaches for developing quality checklists in healthcare organizations: A scoping review
Kwong, E. C., Cole, A. C., Byrd, E., Sippo, D. A., Yu, F., Adapa, K., Shea, C. M., Moore, C., Das, S. K., & Mazur, L. M. (2025) · PLOS Digital Health · doi:10.1371/journal.pdig.0001015 · Cited by 2
“…for Patient Safety (SEIPS) model [50] Focuses on system design and its impact on processes, outcomes, and their relationships for patient safety [84] 1 3% APA’s App Evaluation Model [44,45] Hierarchical model applied to selecting apps [44] 1 3% Normalization Process Theory (NPT) [53,54] Focuses…”
Health Care Information Technology Vendors' "Hold Harmless" Clause
Koppel, R., & Kreda, D. (2017) · Cited by 2
A Qualitative Observational Study in Pediatric ICUs
Yang, Y., & Rivera, A. J. (2016) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931213601203 · Cited by 2
“…to the fact that a decision may be influenced by multiple contextual factors of the work system, such as the types and severity of admitted patients, the physical environment, the organizational culture and infrastructure, and the external environment (Carayon et al., 2006; Holden et al., 2013).”
BackgroundNegoescu, E., Marcilly, R., Cromie, S., Koay, A. C. C., & Grimes, T. (2023) · HRB Open Research · doi:10.12688/hrbopenres.13674.1 · Cited by 1
Safety and Quality Assessment in the Pediatric Intensive Care Unit
Scanlon, M. C., & Wakeham, M. (2011) · Elsevier eBooks · doi:10.1016/b978-0-323-07307-3.10007-2 · Cited by 2
Hazard Assessment and Remediation Tool for Simulation-Based Healthcare Facility Design Testing
Smith-Millman, M., Daniels, L., Gallagher, K., et al. (2023) · HERD Health Environments Research & Design Journal · doi:10.1177/19375867231188151 · Cited by 2
“Previous studies focus on categorizing hazards according to existing system-based safety frameworks, such as Safe Design Principles and SEIPS Model 2.0 (Carayon et al., 2006; Colman, Dalpiaz, et al., 2020).”
BackgroundInfluentialAutomation in health care: the need for an ergonomics-based approach
Zayas‐Cabán, T., Valdez, R. S., & Samarth, A. (2023) · Ergonomics · doi:10.1080/00140139.2023.2286915 · Cited by 3
“…person or people who perform them, tools and technologies used, organisational conditions, and the internal as well as external environment in which tasks are performed (Carayon et al. 2006; Carayon 2009; Carayon et al. 2020; Hendrick and Kleiner 2001; Holden et al. 2013; Smith and Sainfort 1989).”
BackgroundThe Internet of Things and Opportunities for Pervasive Safety Monitored Health Environments
Michell, V. A. (2015) · IGI Global eBooks · doi:10.4018/978-1-4666-8756-1.ch079 · Cited by 2
Eriksson, B. K. G., Svartengren, M., Göras, C., Dahlgren, A., Lindblom, J., & Arakelian, E. (2025) · BMJ Open · doi:10.1136/bmjopen-2025-104968 · Cited by 5
“The reasons for declining may be many; however, one reason might be the limitation to release nurses to participate in studies as they are stuck in the OR.”
InfluentialThe Disruption of Patient Ambulation Care Processes by COVID-19
Jones-Hooker, C., Tyndall, D. E., & Forbes, T. H. (2023) · JONA The Journal of Nursing Administration · doi:10.1097/nna.0000000000001328 · Cited by 2
Using human factors principles to redesign a 3D lab workflow during the COVID-19 pandemic
Larsen, E. P., Silvestro, E., Ferro, D. F., et al. (2022) · 3D Printing in Medicine · doi:10.1186/s41205-022-00161-9 · Cited by 2
“Responding to these highly variable conditions is where whole system perspectives like SEIPS are particularly useful [9, 11].”
BackgroundMethodContextual factors affecting learning-oriented leadership in healthcare: a case study
Lørum, R. M., Eriksson, H., & Smith, F. (2025) · Journal of Health Organization and Management · doi:10.1108/jhom-03-2025-0151 · Cited by 2
“The findings and recommendations from this article on contextual complexity, emergent change and differentiated leadership roles may also inform future studies drawing on frameworks such as SEIPS (Carayon et al ., 2006), CFIR (Damschroder et al ., 2009) and MUSIQ (Kaplan et al ., 2012).”
Navigating and understanding clinical governance and risk management in maternity
Blanks, L., & Wright, G. (2023) · Obstetrics Gynaecology & Reproductive Medicine · doi:10.1016/j.ogrm.2023.11.003 · Cited by 2
The Role of Human and Organizational Factors in the Pursuit of One Digital Health
Kuziemsky, C. E. (2023) · Yearbook of Medical Informatics · doi:10.1055/s-0043-1768724 · Cited by 2
A framework for patient access management: consensus from a Delphi panel of US health system leaders
Woodcock, E. W., & Profeta, C. (2025) · BMC Health Services Research · doi:10.1186/s12913-025-12561-8 · Cited by 2
“The Systems Engineering Initiative for Patient Safety (SEIPS) model emphasizes the integration of human factors and systems production to optimize health care processes and outcomes [3, 18].”
Suresh, V., Nimbarte, A. D., Ryu, J., et al. (2024) · Applied Ergonomics · doi:10.1016/j.apergo.2024.104280 · Cited by 2
Situational awareness in driving, and lessons for surgeons
Markose, G., Berezowski, B. M., Chiu, G. A., et al. (2020) · British Journal of Oral and Maxillofacial Surgery · doi:10.1016/j.bjoms.2020.11.003 · Cited by 2
Pasientsikkerhet og velferdsteknologi – parhester i utakt
Stokke, R., Furnes, M., Vifladt, A., & Odberg, K. R. (2020) · Tidsskrift for omsorgsforskning · doi:10.18261/issn.2387-5984-2020-02-12 · Cited by 2
The Singapore Green Plan 2030: occupational health hazards in the Singapore green economy
Lim, W. X., Tan, M. L. L., Teo, T. L. S., et al. (2025) · Singapore Medical Journal · doi:10.4103/singaporemedj.smj-2024-121 · Cited by 2
“[47] A human factor‑based model used in health care, SEIPS is traditionally used for root cause analyses of patient safety incidents, but has also been recently adapted to critically evaluate measures to minimise the risk of intra‑hospital transmission and protect frontline healthcare workers…”
Frameworks for Evaluating the Impact of Safety Technology Use
Cho, I. (2023) · Healthcare Informatics Research · doi:10.4258/hir.2023.29.2.89 · Cited by 2
“The System Engineering Initiative for Patient Safety (SEIPS) model is a systems-based framework for identifying healthcare factors contributing to patient safety incidents [11].”
MethodCedars, B. E., Lisker, S., Borno, H. T., et al. (2019) · Pilot and Feasibility Studies · doi:10.1186/s40814-019-0482-x · Cited by 2
Snyder, M. E., Nguyen, K. A., Patel, H., et al. (2024) · BMC Health Services Research · doi:10.1186/s12913-024-11690-w · Cited by 2
“We applied the SEIPS constructs in the development of a priori deductive codes [16–18].”
MethodPerceptions of cognitive workload measurement using multimodal sensors in surgery
Naik, R., Fehervari, M., Ali, R., Hazell, G. A., Kutaiman, T., Singh, R., Vijayanarasimhan, R., Mylonas, G. P., Ashrafian, H., & Darzi, A. W. (2024) · Global Surgical Education - Journal of the Association for Surgical Education · doi:10.1007/s44186-024-00285-y · Cited by 2
“…be used to improve the cognitive ergonomics of surgery, provide quantifiable measures of surgeon workload and improve patient safety in the context of the Systems Engineering Initiative for Patient Safety (SEIPS) model by incorporating human factors and systems engineering with technology [47, 48].”
Inefficient Processes and Associated Factors in Primary Care Nursing: System Configuration Analysis
Tarver, W. L., Savoy, A. W., Patel, H., Weiner, M., & Holden, R. J. (2023) · JMIR Human Factors · doi:10.2196/49691 · Cited by 2
“The original SEIPS framework [24] has been identified as a means of describing and evaluating processes in primary care by taking into account the complex, interconnected socio-technical aspects found in the health care system [25].”
MethodBonsch, R., Seibt, R., Krämer, B., Rieger, M. A., Steinhilber, B., & Luger, T. (2024) · Life · doi:10.3390/life14040426 · Cited by 2
“The reason for this is that different work system factors may influence the perception of the different workload dimensions, such as team coordination, task content, availability of medical tools, and work station design [38,58].”
BackgroundNegotiating Time and Space: Investigating the Pediatric Code Cart Augmented Reality Application
Ramadhani, W., Wooldridge, A. R., Roychowdhury, J., et al. (2020) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1071181320641326 · Cited by 2
“…introduction of a new technology for training clinicians about pediatric code cart, we applied the Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al., 2006; Carayon et al., 2014) to identify work system barriers and facilitators encountered by users of the application.”
MethodCOMPORTAMIENTO DE LA MATRICULA EN LOS CENTROS REGIONALES DE LA UTP PARA EL AÑO 2017
de Panamá, U. T., Maestre, C., Rodríguez, I., et al. (2021) · doi:10.47300/978-9962-5599-8-6-14 · Cited by 2
Human Factors and Systems Approach to Patient Safety
Spurgeon, P. C., Sujan, M. A., Cross, S., & Flanagan, H. (2019) · Springer eBooks · doi:10.1007/978-3-030-18244-1_3 · Cited by 2
Cowdell, F., Harvey, H., & Dyson, J. (2025) · International Journal of Older People Nursing · doi:10.1111/opn.70036 · Cited by 2
Team-Communication Modeling Framework for Multi-Unit Nuclear Power Plant Accident Analysis
Salim, S., Yeom, S.-Y., & Ham, D.-H. (2025) · Applied Sciences · doi:10.3390/app15095096 · Cited by 2
Ouda, E., Chaabi, I. M., Abualola, H., Ramadan, M. A., Patro, P. K., Kaya, G. K., & Simsekler, M. C. E. (2026) · Risk Management and Healthcare Policy · doi:10.2147/rmhp.s573762 · Cited by 2
“22 Systems thinking enables researchers and practitioners to explore how technologies influence workflow dynamics, stakeholder roles, regulatory processes, and organizational constraints.”
Understanding How Things go Wrong
Vincent, C. A. (2010) · Patient Safety · doi:10.1002/9781444323856.ch8 · Cited by 2
Sharafkhani, M., Geary, Ú., Kennedy, C., Browne, M., Codd, M., O’Dea, A., Shields, D., Hennessy, A., McDonagh, L., O’Hara, S., et al. (2025) · Theoretical and Applied Ergonomics · doi:10.3390/tae1010005 · Cited by 6
“HFE STSA has been applied previously to understand and improve handover in some hospital departments—for example, trauma and orthopaedic surgery [20] and intensive care units (ICUs) [21].”
Wenderott, K., Krups, J., & Weigl, M. (2026) · BMJ Open Quality · doi:10.1136/bmjoq-2025-003639 · Cited by 5
“13 It outlines key elements of clinical work systems – people, tasks, tools and technologies, organisation and environment – and highlights how these elements interact.”
Safety Interventions in Cardiac Anesthesia: A Systematic Review
O'Callaghan, L., Ahern, S., & Doyle, A. J. (2024) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2024.12.004 · Cited by 2
Karamoskos, P. (2026) · American Journal of Roentgenology · doi:10.2214/ajr.26.34634 · Cited by 2
Tabibzadeh, M., & Patel, Z. (2020) · Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care · doi:10.1177/2327857920091050 · Cited by 2
“Some of the previous studies on proactive risk assessment primarily focus on hazards – or “risk factors” that increase the probability of errors or injuries in healthcare settings (e.g. Carayon et al., 2006; Carayon et al., 2014; Karnon et al., 2007; Wooldridge et al., 2017).”
BackgroundFord, J. H., Nora, A., & Crnich, C. J. (2023) · Implementation Science Communications · doi:10.1186/s43058-023-00535-y · Cited by 2
“A hybrid deductive-inductive approach, based on the Systems Engineering Initiative for Patient Safety (SEIPS) model [17], was used to analyze the coach notes documented from June 2019 to March 2020 ( n = 148).”
MethodAlbolino, S., Luca, M. D., & Morabito, A. (2020) · Springer eBooks · doi:10.1007/978-3-030-59403-9_21 · Cited by 3
Surgical Specialty and Case Number May Influence Surgeon Workload
Niichel, M. K., Lowndes, B. R., Linden, A. R., et al. (2019) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1071181319631490 · Cited by 2
Applying a Human Factors Approach to Improve Patient Experience with Sacral Neuromodulation
Cohen, T., Kanji, F. F., Burton, C., et al. (2021) · Urology · doi:10.1016/j.urology.2021.05.007 · Cited by 2
Identifying resilience: a system safety review of trauma and orthopaedic theatres
Wills, V. E. (2024) · Ergonomics · doi:10.1080/00140139.2024.2343930 · Cited by 2
“a systems analysis using seiPs (carayon et al. 2006; holden et al., 2013), was conducted during a facilitated face to face workshop with approximately 40 multidisciplinary team (MDt) members from theatres. staff were split into seven groups, one for each of the sections of the elective orthopaedic…”
Connell, K. A., Yu, H., Villani, D., McHugh, M. D., & Douglas, C. (2026) · Research in Nursing & Health · doi:10.1002/nur.70056 · Cited by 2
“The Systems Engineering Initiative for Patient Safety (SEIPS) model explicitly conceptualizes how work system characteristics influence care processes, which, in turn, affect patient outcomes (Carayon et al. 2006).”
Setayesh, A., Greig, M. A., Grosse, E. H., Glock, C. H., & Neumann, P. (2024) · Ergonomics · doi:10.1080/00140139.2024.2389287 · Cited by 3
“…workstation design, and individual traits. similarly, in healthcare, hF has been linked to quality and patient safety issues (carayon et al. 2020; carayon et al. 2006). enhancing person-centred design in work structures and processes in healthcare is critical to improving care quality and, thus,…”
Larsen, E. P., Jalloul, M., & Larsen, M. P. (2025) · American Journal of Clinical Pathology · doi:10.1093/ajcp/aqaf024 · Cited by 2
Zhang, S., & Gu, X. (2025) · Cognition Technology & Work · doi:10.1007/s10111-025-00796-8 · Cited by 3
“The SEIPS model, as a representative model of HFE applied in healthcare, not only describes the cur - rent state of the work system but also provides opportunities for future cyclical optimisation (Carayon et al. 2006; Pascale et al. 2022).”
Are chain pharmacy work system characteristics associated with work-life outcomes? A national study
Nadi, S., Arya, V. A., Bakken, B. K., et al. (2026) · Journal of the American Pharmacists Association · doi:10.1016/j.japh.2026.103024 · Cited by 2
Isabelle, M., Ip, I. K., Bakhtin, M., et al. (2025) · JAMIA Open · doi:10.1093/jamiaopen/ooaf085 · Cited by 2
“29 The model consists of 3 major components: the “Work System,” the “Process of Care,” and “Team Outcomes.””
Blocker, R. C., Forsyth, K. L., & Hawthorne, H. J. (2018) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931218621070 · Cited by 2
Parks, R., & Ramly, E. (2023) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/21695067231192253 · Cited by 3
“Assessing complex user needs is a particular strength of HF, with approaches like work systems analyses capturing the local system and the interacting barriers and facilitators therein (Carayon et al., 2006; Musu-uza et al., 2019).”
BackgroundProactive Risk Assessment of Team Health IT for Pediatric Trauma Care Transitions (T3)
Hoonakker, P., Carayon, P., Hose, B., et al. (2019) · Advances in intelligent systems and computing · doi:10.1007/978-3-030-24067-7_25 · Cited by 2
Self-citationCompliance with the Surgery Safety Checklist: An Update on the Status
Lorkowski, J., Maciejowska-Wilcock, I., & Pokorski, M. (2021) · Advances in experimental medicine and biology · doi:10.1007/5584_2021_661 · Cited by 2
van Nie‐Visser, N. C. (2014) · doi:10.26481/dis.20141031nn · Cited by 2
Martínez, C. S., Paulsson, M., González-Suárez, S., et al. (2024) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzae020 · Cited by 2
Rheumatology Clinic Staff Needs
Tong, M., Gilmore‐Bykovskyi, A. L., Block, L., Ramly, E., White, D. W., Messina, M. L., & Bartels, C. M. (2022) · JCR Journal of Clinical Rheumatology · doi:10.1097/rhu.0000000000001868 · Cited by 2
Maximizing student potential: Lessons for pharmacy programs from the patient safety movement
Abebe, E., Bao, A., Kokkinias, P., Russ, A. L., & Degnan, D. (2022) · Exploratory Research in Clinical and Social Pharmacy · doi:10.1016/j.rcsop.2022.100216 · Cited by 2
Medication Errors and Trainees: Advice for Learners and Organizations
Wheeler, J. S., Duncan, R., & Hohmeier, K. C. (2017) · Annals of Pharmacotherapy · doi:10.1177/1060028017725092 · Cited by 2
Demonstration of Innovative Techniques for Work Zone Safety Data Analysis
Duffy, S. F., & McAvoy, D. (2009) · ROSA P · Cited by 2
Work System Barriers and Facilitators to Compliance with Infection Prevention Intervention
Hundt, A. S., Ngam, C. R., Carayon, P., Haun, N., & Safdar, N. (2016) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931213601126 · Cited by 2
“In this study we aimed to gain a better understanding of the work system barriers and facilitators (Carayon, Gurses, Hundt, Ayoub, & Alvarado, 2005; Carayon et al., 2006) to compliance with the CDI bundle from the perspective of three different groups of healthcare workers who regularly interact with CDI patients and…”
BackgroundSelf-citationSevitz, J. S., Rogus‐Pulia, N. M., Malandraki, G. A., & Troche, M. S. (2025) · Journal of Speech Language and Hearing Research · doi:10.1044/2025_jslhr-24-00768 · Cited by 3
A Briefing Regarding In Situ Simulation
Kosik, E. S. (2015) · International Anesthesiology Clinics · doi:10.1097/aia.0000000000000080 · Cited by 2
“The Systems Engineering Initiative for Patient Safety (SEIPS) model focuses attention on how systems affect work processes and quality and safety of care.(16) The SEIPS model is descriptive and considers the person, organization, tools and technology, the task, and the physical environment in patient care.”
BackgroundMacroergonomics Past, Present, and Future
Alfred, P., Rice, V. J. B., Kleiner, B. M., Imada, A. S., Carayon, P., & Robertson, M. (2011) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1071181311551235 · Cited by 2
Self-citationEnhancing Margin Precision: A Work System Approach to Lumpectomies and Mastectomies
Nadri, C., Skurnak, K., Zoaktafi, M., et al. (2025) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/10711813251369400 · Cited by 2
“During the observations, we collected detailed observation notes guided by the SEIPS model (Carayon et al., 2006) to capture work involved in each case in the operating room, radiology and pathology laboratory.”
InfluentialMoving forward from the mid-career: Path options and strategies for mid-career academics
Bass, E. J., Bisantz, A. M., Cao, C. G. L., et al. (2019) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1071181319631239 · Cited by 2
Self-citationSystems approaches to risk assessing healthcare, how far have we come?
Buckle, P. (2012) · Work · doi:10.3233/wor-2012-0090-3847 · Cited by 2
Salwei, M. E., & Reale, C. (2024) · JAMIA Open · doi:10.1093/jamiaopen/ooae053 · Cited by 3
“34 This is grounded in the Systems Engineering Initiative for Patient Safety (SEIPS) model, 35,36 in which the work system influences the processes of care (or workflows), which in turn lead to system outcomes (eg, quality of decisions, patient safety, burnout).”
BackgroundOdberg, K. R., Aase, K., Grusd, E., et al. (2025) · BMC Emergency Medicine · doi:10.1186/s12873-025-01213-z · Cited by 2
“An interview guide (Supplementary file 2) was developed, informed by the medication administration process [14] and the work system elements of the SEIPS model [8].”
InfluentialUsing a Systems Approach to Understand Quality Improvement in a Nursing Home in Japan
Kodate, N., Obayashi, K., Mannan, H., & Masuyama, S. (2022) · Oxford University Press eBooks · doi:10.1093/oso/9780198799498.003.0015 · Cited by 2
Super, I., Zhang, L., Wang, B., & Asan, O. (2025) · Applied Ergonomics · doi:10.1016/j.apergo.2025.104535 · Cited by 2
Buttiġieġ, S. C., Azzopardi, E.-A., & Cassar, V. (2019) · Emerald Group Publishing Limited eBooks · doi:10.1108/s1474-823120190000018005 · Cited by 2
Daraiseh, N. M., & Summerville, L. A. (2016) · IIE Transactions on Occupational Ergonomics and Human Factors · doi:10.1080/21577323.2016.1183535 · Cited by 2
“SEIPS 2.0 describes organizational factors as those “that organize time, space, resources and activity” (Holden et al. 2013, p. 5); encompassing schedules, patient assignments, culture, training, policies, and the availability of resources.”
MethodInfluentialDietz, A. S., Bell, M., Drews, F. A., et al. (2017) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931213601643 · Cited by 2
Self-citationDamiaens, A., & Foulon, V. (2025) · Research in Social and Administrative Pharmacy · doi:10.1016/j.sapharm.2025.04.006 · Cited by 2
Kazemi, R. J., Snee, I. A., Lenze, N. R., et al. (2025) · Tracheostomy Official Journal of the Global Tracheostomy Collaborative · doi:10.62905/001c.141114 · Cited by 2
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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