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 1,201–1,300 of 1,789
Fell, S. E., Bowie, P., Spalding, K., et al. (2024) · BMJ Open Quality · doi:10.1136/bmjoq-2023-002655 · Cited by 2
“The cards incorporate concepts from General Systems Theory, 10 Complex Systems Theory, 11 Socio-technical Systems Theory 12 and Resilience Engineering (RE).”
BackgroundMethodHahn, F., Heller, J., Steger, A., Rattka, M., Federle, D., Gehrmann, J., Laugwitz, K., Barthel, P., Arens, M., Veith, S., et al. (2025) · Journal of Public Health · doi:10.1007/s10389-025-02547-5 · Cited by 3
Team Adaptation to Complex Clinical Situations: The Case of VTE Prophylaxis in Hospitalized Patients
Salwei, M. E., Carayon, P., Hundt, A. S., Kleinschmidt, P. C., Hoonakker, P., Patterson, B. W., & Wiegmann, D. A. (2018) · Advances in intelligent systems and computing · doi:10.1007/978-3-319-96098-2_32 · Cited by 2
Self-citationHuman Factors Engineering-as-a-Service in Cybersecurity
Nobles, C., Rangarajan, A., & Burrell, D. N. (2025) · IGI Global eBooks · doi:10.4018/979-8-3693-6437-6.ch014 · Cited by 2
Sim, W. H. (2025) · Journal of Patient Safety · doi:10.1097/pts.0000000000001345 · Cited by 2
“Thus, the goal of this study was to (1) develop a nurse-targeted medication administration error prevention program based on the SEIPS model, 12 (2) verify its validity by applying it in an adult general ward, assessing nurses ’ awareness of patient safety culture and medication safety compliance,…”
Safety-II and the study of healthcare safety routines: Two paths forward for research
Rydenfält, C. (2022) · Journal of Patient Safety and Risk Management · doi:10.1177/25160435221102129 · Cited by 2
“0 could be of interest.(37,38) However, since the SEIPs framework focuses on the patient journey, I suggest a widening of the journey concept to include the interaction of several journeys, including not only patients and personnel, but also tools, and information, in relation to the potential event or object of study.”
BackgroundMakeham, M., Jayawardena, T. D., Elkheir, S., Carrigan, A., Soumya, S., Russell, H. A., Prgomet, M., Tyagi, V., Huben, A. V., Baysari, M. T., et al. (2025) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2025.106218 · Cited by 2
Assessment of the Impacts from the Addition of Novel Assistive Technologies in Mental Health Care
Garafalo, J., & Nathan-Roberts, D. (2016) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931213601290 · Cited by 2
“The SEIPS 2.0 model is broken down into work system factors, process, and outcomes (Holden et al., 2013; Carayon et al., 2006).”
MethodInfluentialOlivencia, S. B., Hegde, S., & Sasangohar, F. (2020) · IISE Transactions on Healthcare Systems Engineering · doi:10.1080/24725579.2020.1834033 · Cited by 2
Khunlertkit, A., & Jantzi, N. (2016) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931213601125 · Cited by 2
“The Systems Engineering Initiative for Patient Safety (SEIPS) framework (Carayon et al., 2006) was utilized as a guiding principle for this RCA to address lack of vaccine documentation in a pediatric primary care clinic.”
MethodCastro, G. M. (2014) · ProQuest Demo Repository · Cited by 2
Qureshi, S. M. (2021) · doi:10.32920/ryerson.14663319 · Cited by 2
Ferguson, A., Newham, R., Dunlop, E., Preston, K., & Bennie, M. (2025) · BMJ Open Quality · doi:10.1136/bmjoq-2024-003023 · Cited by 3
“This would provide an opportunity to develop an evidence base of the facilitators and barriers to using teleconsultations, which could add to future research exploring use in healthcare settings where engagement with teleconsultations has been limited.”
Seale, D. E., LeRouge, C., & Kolotylo-Kulkarni, M. (2023) · Journal of Medical Internet Research · doi:10.2196/42330 · Cited by 3
“The model was adapted based on prior frameworks [16-18] in a deductive-inductive fashion to incorporate both existing research [16-18] and the findings of this study.”
Hildebrand, E. A. (2014) · Cited by 2
Surgical measurement framework: A new framework for quality care in surgical specialties
Hart, C. K., Ishman, S. L., & Alessandrini, E. A. (2016) · Perioperative Care and Operating Room Management · doi:10.1016/j.pcorm.2016.01.005 · Cited by 2
Joseph, A., Mihandoust, S., Ardekani, M. S., Dietrich, A. M., Narasimhan, M., & RIPCHD.PED Study Group (2025) · Journal of Patient Safety · doi:10.1097/pts.0000000000001357 · Cited by 2
Ergonomía y factores humanos en la lucha contra el COVID-19
Galindo, C. M. E. (2020) · Revista Médica Herediana · doi:10.20453/rmh.v31i3.3815 · Cited by 2
Sujan, M. A., Crumpton, E., Finch, V., & Combes, J. (2024) · Human Factors in Healthcare · doi:10.1016/j.hfh.2024.100075 · Cited by 2
Cohen, T., Kanji, F. F., & Anger, J. T. (2024) · Urology · doi:10.1016/j.urology.2024.09.010 · Cited by 2
Productivity and Safety Improvement in Industry Using Ergonomics—A Case Study
Dora, H. K. M., Krishna, L. S. R., & Reddy, P. R. (2022) · Lecture notes in mechanical engineering · doi:10.1007/978-981-19-5347-7_1 · Cited by 1
Khunlertkit, A., Rivera, A. J., Yin, S., Dulude, C., Regli, S. H., & Wolf, L. (2016) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931213601150 · Cited by 2
“Lack of consideration of HF principles in healthcare design could result in poor quality of care (IOM, 2006; Reid et al., 2005) as well as negative employee outcomes (e.g., work overload and turnover) (Carayon et al., 2006).”
BackgroundOrtega, A., & Goulding, T. (2021) · Clinical journal of oncology nursing · doi:10.1188/21.cjon.201-204 · Cited by 1
CONCEPTUAL FOUNDATION OF SAFER GUIDES
Sittig, D. F., & Singh, H. (2015) · Apple Academic Press eBooks · doi:10.1201/b18371-5 · Cited by 1
Lee, H., Nam, H. J., Kim, B. H., & Yoon, J. Y. (2025) · Journal of Korean Academy of Nursing · doi:10.4040/jkan.25018 · Cited by 1
Multidimensional approach to clinical quality
Palteki, T. (2019) · Southern Clinics of Istanbul Eurasia · doi:10.14744/scie.2019.04274 · Cited by 1
“[26] Carayon et al.[27] (2006) indicated that interactions between individuals and work environment are effective on performance, safety, quality of work-life, employee health, the quality of goods produced and services provided.”
BackgroundHuman Factors Engineering for the Pediatric Hospitalist
Luo, B. T., Barton, H. J., Wooldridge, A. R., & Kelly, M. M. (2023) · Hospital Pediatrics · doi:10.1542/hpeds.2023-007258 · Cited by 1
Patient Safety Incident Differences Between Accredited and not Accredited Primary Health Center
Dewi, A., Seftaviani, N., & Rochmawati, E. (2019) · JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit) · doi:10.18196/jmmr.83109 · Cited by 1
The Intersection of Human Factors and Evidence-Based Healthcare Design: A Conceptual Framework
Jiang, S., Mazzi, A., Miller, K., Wolf, L., Peng, Y., Sanghavi, H. K., Tetteh, E., Schwartz, M. H., McCray, M. M., Graske, A., et al. (2025) · HERD Health Environments Research & Design Journal · doi:10.1177/19375867251332618 · Cited by 1
“This model attempts to simplify the complex dynamics of the healthcare environment (Carayon et al., 2006).”
A Systems Approach into Unnecessary Admissions and Readmissions in Emergency Departments
Bonet, S. A., & Sasangohar, F. (2019) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1071181319631246 · Cited by 1
“The application of human factors (HF) and systems engineering (SE) methods, such as Qualitative Data Analysis (QDA) and the Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al., 2006), facilitated the analysis of the data and the representation of the results.”
MethodLoosen, J. A., Schmitz, E. J., Hermann, C., et al. (2021) · Journal of the American Geriatrics Society · doi:10.1111/jgs.17039 · Cited by 1
“The five components of the SEIPS model work system are people, tools and technologies, organization, environment, and tasks—all of which influence processes and final outcomes.(6) Herein we describe a practical SEIPS-based recruitment design for hospitalized patients with dementia and report on its initial feasibility…”
BackgroundThe Nature of Systems in Healthcare
Ponnala, S., Valdez, R. S., McGuire, K., & Valdez, J. A. (2021) · Comprehensive healthcare simulation · doi:10.1007/978-3-030-72973-8_1 · Cited by 1
Improving Performance, Reducing Error, and Minimizing Risk in the Delivery Room
Halamek, L. P., & Yamada, N. K. (2003) · Cambridge University Press eBooks · doi:10.1017/9781009418034.045 · Cited by 1
Using SEIPS 101 Tools to Model Surgical Count Processes
Meilan, J., Lusk, C., Galinsky, E. K., et al. (2025) · Journal of Patient Safety · doi:10.1097/pts.0000000000001386 · Cited by 1
Borges, J. Y. V. (2026) · SSRN Electronic Journal · doi:10.2139/ssrn.6159427 · Cited by 1
Handoffs and Medication Errors: A Community Hospital Case Study
Chircu, A. M., Gogan, J. L., Baxter, R. J., & Boss, S. R. (2011) · Hawaii International Conference on System Sciences (HICSS) · doi:10.1109/hicss.2011.218 · Cited by 1
“Other engineering and design disciplines -- such as systems engineering, human factors and quality engineering -have also been utilized in patient safety studies [9, 13].”
Backgroundde Vries, M., Hall, L. M., Dainty, K. N., Fan, M., Tscheng, D., Hamilton, M., & Trbovich, P. (2025) · Research in Social and Administrative Pharmacy · doi:10.1016/j.sapharm.2025.01.001 · Cited by 2
y Tecnología, U. I. D. C., Ortega, M. I. V., Zeballos, R., et al. (2021) · doi:10.47300/978-9962-5599-8-6-15 · Cited by 1
Change Management in Oncology Nursing Practice
Tsatsou, I. (2025) · Journal of Current Health Sciences · doi:10.47679/jchs.2025113 · Cited by 1
Dorsey, S., Pullmann, M. D., Kerns, S. E. U., Deblinger, E., Lucid, L., Harrison, J. P., Thompson, K., & Berliner, L. (2018) · Implementation Science · doi:10.1186/s13012-018-0715-z · Cited by 2
Schreiber, R., & McGreevey, J. D. (2023) · Elsevier eBooks · doi:10.1016/b978-0-323-91200-6.00009-7 · Cited by 1
Versaevel, C., Bruneel, B. Y., HERZEELE, I. V., et al. (2024) · Acta Anaesthesiologica Belgica · doi:10.56126/75.3.55 · Cited by 1
Jacob, D., Chewning, B. A., & Ford, J. H. (2025) · Exploratory Research in Clinical and Social Pharmacy · doi:10.1016/j.rcsop.2025.100572 · Cited by 1
“20 The care processes through which a resident receives an antibiotic is dependent on the organizational work system of the ALF and the interaction of components within that work system.”
Nyembwe, J.-P. K. B., Ogundiran, J. O., Lukumwena, N., et al. (2025) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph22101511 · Cited by 1
“Optimal performance, on the other hand, occurs within a specific physical environment [14].”
Exploring Medication Safety in Transitions From Prison to Community: A Qualitative Study
Planner, C., Keers, R. N., Phipps, D. L., Eylem, Ö., Tyler, N., Shaw, J. J., Ashcroft, D. M., & Panagioti, M. (2026) · Health Expectations · doi:10.1111/hex.70684 · Cited by 1
“Prompts were informed by the Systems Engineering Initiative for Patient Safety (SEIPS) framework [29], enabling exploration of interactions between system elements, human behaviour, tools, tasks, and organisational context.”
Green, N., Tappin, D., & Bentley, T. A. (2018) · Advances in intelligent systems and computing · doi:10.1007/978-3-319-96098-2_25 · Cited by 1
Safety and quality: Two basic components of contemporary surgical care
Nomikos, I. N. (2017) · Hellenic Journal of Surgery · doi:10.1007/s13126-017-0400-8 · Cited by 1
“In an effort to further conceptualize this system there, a model has been constructed based on three basic qualitative factors that constitute the infrastructure of the system: structure, process and outcomes [10].”
MethodNadhrah, N., & Michell, V. A. (2014) · IGI Global eBooks · doi:10.4018/978-1-4666-6339-8.ch016 · Cited by 1
Cohen, T., Anger, J. T., Barton, H. J., Blumenthal, J. S., Gosman, A. A., Kanji, F. F., Khamisa, R., Koola, J., Lewis, P., Marinković, M. D., et al. (2025) · Journal of Patient Safety · doi:10.1097/pts.0000000000001383 · Cited by 1
Svensberg, K., Axelsson, L., & Hellström, L. (2025) · Exploratory Research in Clinical and Social Pharmacy · doi:10.1016/j.rcsop.2025.100657 · Cited by 2
“25 The work process describes how the work operates based on the structure of the work system.”
y Tecnología, U. I. D. C., Suárez, I. R., Castillo, Z., et al. (2021) · doi:10.47300/978-9962-5599-8-6-13 · Cited by 1
Lucas, S. R., Pollak, E. I., & Makowski, C. T. (2022) · Journal of Healthcare Risk Management · doi:10.1002/jhrm.21529 · Cited by 1
Innovating Emergency Nursing Tools and Technology: Work Design for Quality and Patient Safety
Castner, J. (2019) · Journal of Emergency Nursing · doi:10.1016/j.jen.2019.07.012 · Cited by 1
“” Emergency care work systems are dependent on multiple tools and technologies.(6,7) This issue of the Journal of Emergency Nursing (JEN) features tools and technologies for emergency care.”
BackgroundA human factors engineering approach to improving hand hygiene quality
Boyce, M. W., Mathew, T. A., Roberts, S. C., Aniskiewicz, M. J., Krechevsky, K., Dahlberg, S. E., Frye, N., Trumpler, J. E., Evans, L. V., & Martinello, R. A. (2024) · Human Factors in Healthcare · doi:10.1016/j.hfh.2024.100085 · Cited by 1
Observing sources of system resilience using in situ alarm simulations
McLoone, M., McNamara, M., Jennings, M., et al. (2023) · Journal of Hospital Medicine · doi:10.1002/jhm.13217 · Cited by 1
Kaufman, D. R., Senathirajah, Y., Cato, K., et al. (2023) · Studies in health technology and informatics · doi:10.3233/shti230371 · Cited by 1
“We employed the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework and as a basis to analyze data [3,4].”
Scheer, E. R., Choi, M., Srinivasan, D., Sellers, E., Rogers, C. C., & Valdez, R. S. (2025) · Ergonomics · doi:10.1080/00140139.2025.2567471 · Cited by 1
“…on person, task, and technology-related factors impacting exoskeleton use, researchers must also explore the social, organisational, and environmental landscapes that shape how a diverse range of disabled individuals interact with exoskeleton technology (Carayon et al. 2006; Holden et al. 2013).”
National Research Council Board on Human Systems Integration Panel
Wanchisen, B. A., Cooke, N. J., Carayon, P., et al. (2014) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931214581122 · Cited by 1
“In this presentation, we will describe a systems approach for safe patient handling based on the SEIPS (Systems Engineering Initiative for Patient Safety) model (Carayon et al., 2006) and the systems ergonomics framework of Wilson (2014).”
MethodSelf-citationJun, G., & Clarkson, P. J. (2009) · Cambridge University Engineering Department Publications Database · Cited by 1
Difficult airway management and bidirectional learning in the perioperative setting in Zambia
Eller, J. S., Mumba, K., Phiri, N., et al. (2025) · British Journal of Anaesthesia · doi:10.1016/j.bja.2025.06.022 · Cited by 1
Bowie, P., Davidson, I. A. K., Anderson-Stirling, S., et al. (2023) · IJQHC Communications · doi:10.1093/ijcoms/lyad004 · Cited by 1
Improving Medication-Related Safety for Residents in Nursing Homes: A Qualitative Study
Shieu, B. M., Lee, Y., Epps, F. R., Wang, M.-C., & Harris, J. A. (2025) · Journal of Gerontological Nursing · doi:10.3928/00989134-20250102-03 · Cited by 1
Seo, Y., Hudmon, K. S., Jones, K. L., Yih, Y., Miller, K. D., & Abebe, E. (2025) · Journal of Oncology Pharmacy Practice · doi:10.1177/10781552251323205 · Cited by 1
Huang, E., Hart, J. K., & Won, J. C. (2025) · BMJ Quality & Safety · doi:10.1136/bmjqs-2025-019288 · Cited by 1
“16 It highlights that PS outcomes, staff well-being and organisational performance are shaped not by individual behaviour alone, but by how these components are designed and interrelated.”
Why technology implementation fails: from adoption to dynamic technology integration
Mertens, A., Kho, M. C., Toni, F. D., & Parker, S. K. (2026) · European Journal of Work and Organizational Psychology · doi:10.1080/1359432x.2026.2684522 · Cited by 1
Quality Improvement Methods in Pharmacy Practice Research
Bain, A., & Fowler, D. (2020) · Springer eBooks · doi:10.1007/978-981-15-2993-1_4 · Cited by 2
Newman, J. H. (2014) · Universal Journal of Medical Science · doi:10.13189/ujmsj.2014.020103 · Cited by 1
Farajalla, F., Alqaissi, N. M., Qtait, M. T., et al. (2026) · Nursing Research and Practice · doi:10.1155/nrp/4472112 · Cited by 1
Ausserhofer, D. (2012) · edoc (University of Basel) · doi:10.5451/unibas-006077537 · Cited by 1
Human Factors and Outcomes in Pediatric Cardiac Surgery
Catchpole, K. C. (2014) · Springer eBooks · doi:10.1007/978-1-4471-6566-8_30 · Cited by 1
“The ability of operating room teams to avoid failures or capture them before they can accumulate to infl uence outcome, may be critical [ 7 ] because the cascade of disruptions to a major failure may also be prevented by effective teamwork [ 82 – 85 ].”
BackgroundMethodZhou, Q., Liu, J., Zheng, F., et al. (2024) · BMC Nursing · doi:10.1186/s12912-024-01701-w · Cited by 1
Iftadi, I., Astuti, R. D., & Pristiyana, A. A. (2017) · AIP conference proceedings · doi:10.1063/1.5010658 · Cited by 1
Philipsen, N., Carruthers, W., Chi, G., et al. (2014) · Systems and Information Engineering Design Symposium · doi:10.1109/sieds.2014.6829925 · Cited by 1
“Ergonomics on the Ground”: A Case Study of Service Learning in Ergonomics Education
Davy, J., Weaver, K., Todd, A. I., et al. (2018) · Advances in intelligent systems and computing · doi:10.1007/978-3-319-96065-4_73 · Cited by 1
Cognitive Support for Decisions in the Context of Clinical Workflows
Horsky, J. (2025) · Cognitive informatics in biomedicine and healthcare · doi:10.1007/978-3-031-82971-0_2 · Cited by 1
LAS BUENAS PRÁCTICAS EDUCATIVAS CON EL USO DE LA TECNOLOGÍA: UNA EXPERIENCIA DE APRENDIZAJE
y Tecnología, U. I. D. C., Briceño, M., Gómez, N. C. M., et al. (2021) · doi:10.47300/978-9962-5599-8-6-22 · Cited by 1
Do Trauma Activations Affect Interruptions in the Emergency Department?
Forsyth, K. L., Hawthorne, H. J., Linden, A. R., et al. (2017) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931213601645 · Cited by 1
Hickey, M. D., Lisker, S., Brodie, S., Vittinghoff, E., Russell, M. D., & Sarkar, U. (2020) · Pilot and Feasibility Studies · doi:10.1186/s40814-020-0552-0 · Cited by 1
PROCESS DESIGN FOR MULTIDISCIPLINARY PATIENT CARE MEETINGS: CONSIDERING THE HUMAN FACTOR
Vogwill, V., & Chignell, M. (2007) · IFAC Proceedings Volumes · doi:10.3182/20070904-3-kr-2922.00063 · Cited by 1
“, 2006), the StructureProcess-Quality model (Donabedian, 1988), and the Systems Engineering Initiative for Patient Safety (SEIPS) (Carayon et al., 2006).”
BackgroundMethodAlohan, D. I., Hudson, A., Hamilton, C., et al. (2025) · JMIR Research Protocols · doi:10.2196/72283 · Cited by 1
“Given that community pharmacies have a unique work system, implementation science frameworks specific to the pharmacy setting are also needed to enhance our understanding of all of the pharmacy work system components [32].”
Jennings, B. M. (2021) · Nursing Administration Quarterly · doi:10.1097/naq.0000000000000485 · Cited by 1
Maximizing Surgical Success by Aligning Interventions to Outcomes: A Systematic Review
Armstrong, B. A., Tung, A., Lo, L., Abssy, S. S., Zulfiqar, M., van Oost, J., Wong, J., Janevski, J., Martyniuk, J., & Trbovich, P. (2025) · Annals of Surgery Open · doi:10.1097/as9.0000000000000558 · Cited by 1
“The Systems Engineering Initiative for Patient Safety model, 49 which provides a framework for understanding the structures, processes and outcomes and their relationships in healthcare settings, may be particularly helpful in determining which factors are impacting certain surgical outcomes and…”
Methods and Frameworks to Assess Operating Team Resilience: A Scoping Review
Pentland, V., Malhotra, A. R., McGuire, A., Laios, E., Zevin, B., Zuk, A., Giles, A., Reid, K., & Chung, W. (2025) · Journal of Patient Safety · doi:10.1097/pts.0000000000001430 · Cited by 1
Tong, Y., Yan, H. R., Li, X., Chen, G., & Zhang, Z. (2021) · Lecture notes in computer science · doi:10.1007/978-3-030-71055-2_10 · Cited by 1
CancelRx case study: implications for clinic and community pharmacy work systems
Watterson, T. L., Stone, J. A., Kleinschmidt, P. C., & Chui, M. A. (2023) · BMC Health Services Research · doi:10.21203/rs.3.rs-2859918/v1 · Cited by 2
“Within the SEIPS framework, a work system is comprised of five interconnected social and technical components (person, organization, technologies and tools, tasks, and [physical] environment) that impact how care is provided and the resulting patient outcomes [22].”
BackgroundMethodDefining the contribution of human error to adverse events in a surgical service
Wain, H., Clarke, D., & Wall, S. (2024) · South African Journal of Surgery · doi:10.36303/sajs.00381 · Cited by 1
Guidance for Writing a Clinical Informatics Case Report
Sakumoto, M., & Nielson, J. A. (2022) · ACI Open · doi:10.1055/s-0042-1749195 · Cited by 1
Human Factors to Improve Patient Safety
Purchase, T., Bowie, P., Hibbert, P. D., Krishnan, R. G., & Carson‐Stevens, A. (2023) · Springer eBooks · doi:10.1007/978-3-031-35933-0_4 · Cited by 1
Sustainability of a PICU Situation Awareness Intervention: A Qualitative Study
Dewan, M. L., Prideaux, J., Loeb, D., Patel, R. V., Zackoff, M. W., Kudchadkar, S. R., Vaughn, L. M., & Schondelmeyer, A. C. (2024) · Pediatric Quality and Safety · doi:10.1097/pq9.0000000000000757 · Cited by 1
Thisakya, G., & Dissanayake, P. (2026) · Facilities · doi:10.1108/f-10-2025-0187 · Cited by 1
Development and psychometric testing of a scale to measure effective rural emergency transfer (RET)
Mamalelala, T. T., Holzemer, W. L., Seloilwe, E., & Iwu, E. (2024) · BMC Emergency Medicine · doi:10.1186/s12873-024-01046-2 · Cited by 1
Development and Implementation of a New Process to Improve Safety of Urgent Direct Admissions
Hart, J. K., Kuhn, E., Nord, E., et al. (2025) · Hospital Pediatrics · doi:10.1542/hpeds.2024-008239 · Cited by 1
LAS COMPETENCIAS INVESTIGATIVAS EN DOCENTES DE LAS UNIVERSIDADES PARTICULARES DE PANAMÁ
del Caribe, U., González, S. R., Chirinos, N. M., et al. (2021) · doi:10.47300/978-9962-5599-8-6-10 · Cited by 1
Patient-Oriented Workflow Approach
Ozkaynak, M., Ponnala, S., & Werner, N. E. (2025) · Cognitive informatics in biomedicine and healthcare · doi:10.1007/978-3-031-82971-0_11 · Cited by 1
Human Factors Engineering: Status, Interventions, Future Directions in Pediatrics
Ponnala, S., & Rivera, A. J. (2019) · Current Treatment Options in Pediatrics · doi:10.1007/s40746-019-00157-4 · Cited by 1
Shin, J., Hwang, W., & Kim, N.-Y. (2026) · Healthcare · doi:10.3390/healthcare14070927 · Cited by 1
Rasooly, I. R., Marshall, T. L., Cifra, C. L., Catchpole, K., Kuzma, N. C., Brady, P. W., Melton, K., Khan, A., Chien, A. T., Lipstein, E. A., et al. (2024) · Frontiers in Medicine · doi:10.3389/fmed.2024.1414892 · Cited by 1
“Diagnostic successes and errors will be identified within and across SEIPS work system domains (37) and used to model the system and identify resilience (36).”
MethodA systems approach to understanding SARS-CoV-2 transmission among healthcare workers in a cluster
Pisani, M., Anderson, L., Hatas, G., et al. (2021) · American Journal of Infection Control · doi:10.1016/j.ajic.2021.12.001 · Cited by 1
“This model evaluates multiple facets of the complex healthcare work system to identify factors contributing to an outcome.(2) The [BLINDED] Institutional Review Board deemed this study to be quality improvement and exempt from review.”
Teamwork and Trust for Patient Safety
Lusk, C., & Catchpole, K. C. (2023) · Springer eBooks · doi:10.1007/978-3-031-35933-0_7 · Cited by 1
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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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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