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
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Cited by
Sorted by citations
Items 1,401–1,500 of 1,789
Mohammadinejad, A., Piranveyseh, P., Cousins, R., et al. (2026) · Nursing in Critical Care · doi:10.1111/nicc.70350
“The second larger study by the same authors introduced the Systems Engineering Initiative for Patient Safety (SEIPS) model [27] to examine factors affecting fatigue in registered nurses in various departments, and the barriers and facilitators to nurse coping in hospital settings [26], as well as…”
InfluentialMott, D. A., Gilson, A. M., Aitken, S. L., Johnson, M. D., McCreary, E. K., & Hirsch, E. B. (2026) · JACCP JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY · doi:10.1002/jac5.70288
“Work system characteristics can act like levers that can be manipulated to improve how work is performed by workers and/or improve their work-life [14, 15].”
Karimian, S., Ward, M. E., Corrigan, S., & Brennan, R. (2026) · Communications in computer and information science · doi:10.1007/978-3-032-25809-0_8
Alenazi, A. F. A., Alaoufi, N. M. S., Al-Zurayyir, K. S., et al. (2024) · Journal of Ecohumanism · doi:10.62754/joe.v3i8.5632
Engineering Safe Care Journeys: Designing a Patient Safety Passport
Werner, N. E., Smith, M. A., Rutkowski, R. A., Barton, H. J., Wust, K. L., Hoonakker, P., King, B. J., Shah, M. N., Patterson, B. W., Pulia, M. S., et al. (2025) · Journal of Patient Safety · doi:10.1097/pts.0000000000001397
Self-citationBashatah, J., & Bashatah, A. (2026) · Healthcare · doi:10.3390/healthcare14152344
“According to the Systems Engineering Initiative for Patient Safety (SEIPS) model, the structural and organizational characteristics of healthcare work systems, including how staffing protocols are designed and enforced, are primary determinants of care quality and patient safety outcomes [1].”
When Efficiency Eclipses Care: A Socio-Technical Perspective on Technology in Corporate Dentistry
Kim, D. S. (2026) · ACM Interactive Health Conference · doi:10.1145/3786579.3804929
“The SEIPS model [12] provides a framework for designing work systems that account for the interaction between people, tasks, tools, and organizational conditions—the multidimensional analysis DSO dashboards currently lack.”
Baartmans, M. C., Schoten, S. M. V., & Wagner, C. (2025) · Health Policy and Technology · doi:10.1016/j.hlpt.2025.101068
Intervening Variables of Human Errors in Iranian Public Hospitals
Keikavoosi-Arani, L., Raeissi, P., Tabibi, S. J., et al. (2011)
Georgadarellis, G. L., Benjamin, E., Roberts, S. C., Vital, C. J., & Sup, F. C. (2026) · Journal of Medical Internet Research · doi:10.2196/89409
“SEIPS was created to address the challenge of applying human factors and systems engineering methodologies to improve patient safety research and the design of health care systems [35].”
Human Factors Evaluation of the Use of Workarounds Among Obstetric Nurses
Bernstein, S., O’Brien, L.-M., & Connors, C. (2025) · Journal of Obstetric, Gynecologic & Neonatal Nursing · doi:10.1016/j.jogn.2025.07.004
Hoover, S. (2013) · doi:10.18297/etd/632
“and design of interactions between components contributes to acceptable or unacceptable processes (Carayon et al., 2006) The structural characteristics of the SEIPS model uses a five point work system to evaluate the system processes/interaction between hospitals, primary care clinics and”
MethodInfluentialImproving the Joint Conference: The Roles of Pediatric Cardiologists and Cardiac Surgeons
Kato, A. (2020) · Japanese Society of Pediatric Cardiology and Cardiac Surgery · doi:10.9794/jspccs.36.202
Tome, M., Laurent, X., Georgiev, K., Tolladay, J., Collins, S., Hedgecott, D., Bozhilova, L. V., Hirst, J. E., Impey, L. W. M., & Georgieva, A. (2026) · JMIR Human Factors · doi:10.2196/87589
“Third, Sociotechnical Systems emphasized that technology operates within complex systems of people, processes, and environments [12,36].”
Chrimes, D., Thomo, A., Kuo, M.-H., Borycki, E. M., & Kushniruk, A. W. (2025) · doi:10.2196/preprints.86076
den Ridder, K., Asten, Y. T.-V., van der Tuijn, Y., et al. (2016) · Bohn Stafleu van Loghum eBooks · doi:10.1007/978-90-368-1113-2_4
Galindo, C. M. E., Rojas, R. R. R., Villalobos-Tupia, J. E., et al. (2026) · Springer series in design and innovation · doi:10.1007/978-3-032-23073-7_11
Seeing what nurses see: Eye tracking as a human factors usability tool in healthcare
Becic, I., Roberts, S. C., Pradhan, A. K., et al. (2026) · Advancing Medical-Surgical Nursing · doi:10.1016/j.amsn.2026.100088
Eisawi, A., Aung, M., & Canelo, R. (2020) · BMJ Innovations · doi:10.1136/bmjinnov-2019-000386
Sirago, G., Zotti, F., Mele, F., Misceo, F., Solarino, B., Dell'Erba, A., & Ferorelli, D. (2026) · Journal of Patient Safety · doi:10.1097/pts.0000000000001554 · Cited by 2
Myers, R. B., Jones, S. L., Sittig, D. F., Meeks, D. W., Takian, A., Singh, H., Barber, N., Smith, M. W., Taylor, L., & Scott, J. (2015) · Apple Academic Press eBooks · doi:10.1201/b18371-3
Self-citationGanesan, D., Doraiswamy, R., & Rajkumar, A. (2026) · Cureus · doi:10.7759/cureus.116331
A SEIPS Based Task-Analysis of Informational Inputs Relevant to Patient Placement Decision-Making
Meschievitz-Roman, A. I., Adelaine, S., Houston, T., et al. (2025) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/10711813251361894
“We conducted a deductive content analysis of the observation notes and interview transcripts using the Systems Engineering Initiative for Patient Safety (SEIPS) components, that is, person, task, tool/technology, physical environment, and organization (Carayon et al., 2006).”
Organizational Factor in Patient Safety and Risk Management
Niv, Y., & Tal, Y. (2023) · Springer eBooks · doi:10.1007/978-3-031-49865-7_6
Perspectives on healthcare quality and safety
Russ, S., & Sevdalis, N. (2020) · Oxford University Press eBooks · doi:10.1093/oso/9780198837206.003.0012
Sidhu, S., Anger, J. T., Trasvina, V., et al. (2026) · International Journal for Equity in Health · doi:10.1186/s12939-026-02906-y
“In healthcare, this perspective supports analysis of how people, tools and technologies, tasks, environments, and organizational structures interact to shape care processes and outcomes [12, 13].”
Fujita, W., Kogami, T., Higuchi, A., et al. (2026) · Signals and communication technology · doi:10.1007/978-3-032-18834-2_10
Hastane Operasyon Yönetiminde Dijital İkiz Yazılım Seçimi
Erce, M. İ., Ağırman, S. R., & Pınarbaşı, M. (2026) · International Journal of Advances in Engineering and Pure Sciences · doi:10.7240/jeps.1755977
McCrory, B., Sanders, A., Berg, B., et al. (2026) · Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care · doi:10.1177/2327857926151211
“Applying SEIPS, safety and performance emerge from fit among people, tasks, tools/technology, environment, and organizational conditions (Carayon et al., 2006; Holden & Carayon, 2021).”
Lohtaja, M., Schoultz, A., Mönkkönen, I., et al. (2026) · Exploratory Research in Clinical and Social Pharmacy · doi:10.1016/j.rcsop.2026.100851
“This finding is also consistent with the SEIPS model, 31 which emphasises that patient safety outcomes arise from interactions between multiple work system elements rather than from the actions of individuals alone.”
Butterfly’s Embrace: A Work Systems Analysis of a Hospital-Based Perinatal Bereavement Program
Shelton, E. A., Sutton, L., & Wooldridge, A. R. (2025) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/10711813251370723
“Using the Systems Engineering Initiative for Patient Safety model (SEIPS; Carayon et al., 2006, 2014, 2020), we identified how the program impacted the work system elements—peo-ple, tasks, tools/technology, physical environment, organization and external environment—and interactions between two or…”
Human Factors Ergonomics for Beginners – An Existential Crises: A Reflection on a Working Breakfast
O’Dea, A., & Chadwick, L. M. (2026) · Springer series in design and innovation · doi:10.1007/978-3-032-23073-7_22
Rey-Galindo, J. A., & Álvarez, A. E. D. (2021) · EID Ergonomía Investigación y Desarrollo · doi:10.29393/eid3-15heja20015
Nursing Strategies to Prevent Pressure Injuries in Hospitalized Patients
Alzahrani, N., Alanazi, T. H. B. M., Alenazi, H. S. B., et al. (2024) · International Journal of Computational and Experimental Science and Engineering · doi:10.22399/ijcesen.4060
“This involves collecting and analyzing unit-based pressure injury data, auditing adherence to prevention bundles, and providing feedback to the nursing team [31].”
Cao, P., Leeman, J., Liu, L., Feng, Y., Chen, N., Xiang, F., Wu, Y., Zuo, L., & Zhang, H. (2026) · doi:10.2196/preprints.94817
Medication Errors in Perioperative Nursing: A Scoping Review
Wickramasinghe, C. L., Latimer, S. L., & Gillespie, B. M. (2026) · Journal of Clinical Nursing · doi:10.1111/jocn.70276
Gray, J., Takata, G. S., Lawlor, M. C., et al. (2015) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931215591113
Identifying risks in dementia care: Insights from a qualitative study with clinical pharmacists
Burnand, A., Kantilal, K., Woodward, A., Bhanu, C., Manthorpe, J., Orlu, M., Rait, G., Samsi, K., Sampson, L., Vickerstaff, V., et al. (2025) · PLoS ONE · doi:10.1371/journal.pone.0325472
Modern principles of management of patient safety (systematic review)
Voskanyan, Y. (2018) · Sechenov Medical Journal · doi:10.47093/2218-7332_2018.3.17-24
As’ad, M. (2026) · JMIR Human Factors · doi:10.2196/87846
“From a human factors perspective, this interpretive dilemma reflects a classic problem of decision-making under uncertainty within complex sociotechnical systems [15].”
A Human Factors Approach for Event Analysis in a Pediatric Intensive Care Unit
Cohen, T. (2023) · Journal of Pediatrics & Child Care · doi:10.13188/2380-0534.1000041
“AEs occur within a complex socio-technical healthcare system, in which systems components (humans, tools/technology, tasks, environments, organizations) [6] interact in ways that may contribute to AEs.”
BackgroundYi, Y. M., Lee, S. M., Noh, E.-Y., et al. (2026) · Geriatric Nursing · doi:10.1016/j.gerinurse.2026.103874
Alohan, D. I., Chandra, C., Young, H. N., Quamina, A., Holland, D. P., & Crawford, N. D. (2025) · AIDS Education and Prevention · doi:10.1521/aeap.2025.37.2.107
Heuck, E., & Wooldridge, A. R. (2020) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1071181320641138
“Then, the work system elements described in these excerpts as positively or negatively influencing the care transition in each handoff organization were identified and coded (Carayon et al., 2006; Carayon et al., 2014; Carayon et al., 2020).”
BackgroundMethodInfluentialAmericana, U., Hernández, N. J. U., Barreto, G. A. Q., et al. (2021) · doi:10.47300/978-9962-5599-8-6-05
Demand as the echo of conditions: a leadership lens for understanding system pressure
Whatling, P. J. (2026) · BMJ Leader · doi:10.1136/leader-2026-001668
Weiss, J., Berwa, S., Momanyi, G., et al. (2025) · Antimicrobial Stewardship & Healthcare Epidemiology · doi:10.1017/ash.2025.10111
Muñoz, M. I. C., Barcellini, F., & Nascimento, A. (2012) · HAL (Le Centre pour la Communication Scientifique Directe)
Martínez-Gutiérrez, J., Chima, S., Hunter, B., et al. (2026) · JMIR Cancer · doi:10.2196/90885
“…overcome some of these barriers, a module such as this could be made action-able within the EHR (recalls, tasking, and documentation editable directly from the cohort view) and provide configurable, role-specific triggers to reduce irrelevant pop-ups (which are a known cause of alert fatigue) [29].”
Fennessy, R., Paterson, A., Ward, J., et al. (2026) · Palliative Medicine · doi:10.1177/02692163261437596
Inter-Rater Reliability of Two Error Taxonomies
Jamil, M. J., & Zastrow, R. (2024) · Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care · doi:10.1177/2327857924131075
Osei-Donkor, B., Hassoun, A., & Jabin, M. S. R. (2026) · Frontiers in Health Services · doi:10.3389/frhs.2026.1872556
“These controls align with established safety principles in digital systems, where forcing functions, hard stops, and automated validation are more effective than reliance on user memory or vigilance alone (6, 8, 38).”
InfluentialKey Elements of a Successful ECPR Program
Atlas, N., Mannarino, C. N., McBride, M. E., et al. (2026) · Current Treatment Options in Pediatrics · doi:10.1007/s40746-026-00372-w
Marcilly, R. (2014) · theses.fr (ABES) · doi:10.70675/8a0d9a93zcb2az414cz8de9z5e28fd6ea76d · Cited by 1
Creating an Effective Quality Improvement (QI) Process for Airway Emergencies
Chuo, J., Paliga, J. T., & Lioy, J. (2014) · Springer eBooks · doi:10.1007/978-1-4939-1610-8_32
Bailey, R. C., Hollnagel, F., & Tischendorf, J. S. (2025) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofaf124
“We applied the Systems Engineering Initiative for Patient Safety (SEIPS) model [11] to characterize IMR interview responses using deductive coding framed by the 5 components of the SEIPS model.”
The role of decontamination in reducing healthcare-associated infections
Kirnon, S. (2024) · Nursing Standard · doi:10.7748/ns.2024.e12302
Dowers, K. H., & Jurewicz, K. A. (2023) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/21695067231192194
“The Systems Engineering for Patient Safety (SEIPS) framework can show how different parts of the work system interact and how those areas could potentially lead to errors (Carayon et al., 2006).”
BackgroundDowers, K. H., & Jurewicz, K. A. (2025) · Journal of Infection Prevention · doi:10.1177/17571774251394887
“Healthcare work systems are made of components that interact with one another to result in patient or process outcome (Carayon et al., 2006).”
Communicative Technologies in Nursing Homes: A Framework for Evaluation (Preprint)Preprint
Ali, H. B., & Ahmed, A. (2019) · doi:10.2196/preprints.17254
Otomewo, S. E., & Armstrong, A. (2026) · World Congress on Medical Physics and Biomedical Engineering, September 7 - 12, 2009, Munich, Germany · doi:10.1007/978-3-032-20291-8_27
Practical application of human factors and ergonomics to improve safety
Lachman, P., Brennan, J., Fitzsimons, J., et al. (2022) · doi:10.1093/med/9780192846877.003.0009
Elmore, B., Ikuma, L. H., Nahmens, I., Jagneaux, T., & D’Antonio, C. (2026) · IISE Transactions on Healthcare Systems Engineering · doi:10.1080/24725579.2026.2622417
“…systems engineering framework for improving work processes by examining the related sociotechnical subsystems and evaluates how the technical, personnel and external subsystems interact with each other when changes are implemented (Carayon et al., 2006; Holden et al., 2013; Holden & Carayon, 2021).”
Nurses Work System Optimization: Macroergonomics Perspective
Garosi, E. (2023) · IntechOpen eBooks · doi:10.5772/intechopen.110400
Pardal-Refoyo, J. L. (2014) · Gredos (University of Salamanca)
Campbell, A. R. (2020) · The Scholarship East Carolina University's Institutional Repository (East Carolina University)
Conflict of Interest Disclosure
(2013) · Journal of the American Academy of Dermatology · doi:10.1016/s0190-9622(13)01229-2
Priou, S., Kempf, E., Janković, M., Châtellier, G., & Lamé, G. (2026) · Health Systems · doi:10.1080/20476965.2026.2665355
Asten, Y. T.-V. (2016) · Bohn Stafleu van Loghum eBooks · doi:10.1007/978-90-368-1113-2_5
Obeidat, A. S., Din, A. U., Khan, M. A., et al. (2026) · Healthcare · doi:10.3390/healthcare14070957
“The Systems Engineering Initiative for Patient Safety (SEIPS) framework offers a useful theoretical lens for interpreting this pattern [20].”
Factors Influencing Medication Errors in Clinical Nurses: A Systematic Review and Meta-analysis
Kim, Y.-H., & Ha, Y. K. (2026) · Journal of Patient Safety · doi:10.1097/pts.0000000000001538
Nath, K. C. (2026) · Knowledge-Based Systems · doi:10.1016/j.knosys.2026.116889
Health IT-Enabled Care Coordination and Redesign in Ambulatory Care
Wald, J. S., & Novak, L. L. (2025) · Cognitive informatics in biomedicine and healthcare · doi:10.1007/978-3-031-82971-0_18
Stomlien, T., Julusmoen, S., & Ballangrud, R. (2023) · iNSPIRA · doi:10.23865/inspira.v18.4093 · Cited by 1
THE CONTEXT OF EHR SAFETY AND THE NEED FOR RISK ASSESSMENT
Sittig, D. F., Singh, H., Menon, S., Meyer, A. N. D., & Belmont, E. (2015) · Apple Academic Press eBooks · doi:10.1201/b18371-2
Designing hospitality for health: an emerging approach to public health
Howell, B., Steffy, L., Hill, J. R., et al. (2026) · Frontiers in Public Health · doi:10.3389/fpubh.2026.1858623
Evaluation of Changes to Urine Bags Designed to Improve Visual Ergonomics and Reduce Human Error
Sihombing, A. T., Aly, D., Yantisetiasti, A., et al. (2026) · Ergonomics in Design The Quarterly of Human Factors Applications · doi:10.1177/10648046261422784
‘Sometimes we just have to trust our gut feeling and hope the reporting is good’.
Nilsen, M. K., Sletvold, H., & Olsen, R. M. (2021) · Tidsskrift for omsorgsforskning · doi:10.18261/issn.2387-5984-2021-03-01
Kohanová, D., Gurková, E., Palese, A., Bartoníčková, D., Mazalová, L., Özsaban, A., Bayram, A., Açıl, S. B., Demi̇r, Ö. İ., & Chiappinotto, S. (2026) · Journal of Clinical Nursing · doi:10.1111/jocn.70379 · Cited by 1
“These findings can be interpreted within the SEIPS framework, which conceptua-lises healthcare delivery as a complex work system composed of interacting elements such as individuals, organisational structures, tasks, technologies, and environmental conditions (Carayon et al. 2006).”
From Design to Accountable Impact for Data Dashboards in Health Care
Achuff, B.-J. (2026) · Journal of Medical Internet Research · doi:10.2196/98272
“By providing a structured framework, implementation science and quality improvement reporting guidelines enhance the rigor of these efforts without requiring new trials in every setting [4-6].”
Karlsson, K. A., & Hagberg, I. (2015)
Herdiman, L., Susmartini, S., Pangau, D. A. S., et al. (2023) · Bali Medical Journal · doi:10.15562/bmj.v12i1.4074
Cozmescu, C.-A., Țâncu, A. M. C., Ciocan, L. T., et al. (2026) · Dentistry Journal · doi:10.3390/dj14050267
“In healthcare and medical-device contexts, this perspective is consistent with contemporary risk-management and usability principles, which emphasize interactions among technology, users, tasks, and environment rather than hardware specifications alone [17,18].”
Hong, D., 朱小平, Xu, Y., Jiang, Y., Xiang, X., Xu, F., & Sha, J. (2026) · Medicine · doi:10.1097/md.0000000000050869
“[8] The model is grounded in the work-system and human-factors tradition, in which performance is understood to emerge from the interaction between the worker, the tasks performed, the technologies and tools used, and the physical and organizational environment in which the work takes place.”
Using Systems and Resilience Engineering Literature to Understand Labor and Delivery Work Systems
Nare, M. T., & Jurewicz, K. A. (2025) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/10711813251367740
“Systems thinking approaches, such as the Systems Engineering Initiative for Patient Safety (SEIPS; Carayon et al., 2006) have been used to better understand the variance between “work-as-imag-ined” and “work-as-done.””
InfluentialSafety in health care systems : a synthesis of the literature
Weatherby, J. (2015) · doi:10.6083/m4cf9n4s
YILMAZ, E., Karabay, O., & Altunışık, R. (2022) · Sakarya Medical Journal · doi:10.31832/smj.1073703
The Role of Technology and Medical Devices in Enhancing Pediatric Cardiac Critical Care Outcomes
King, A. L., Baloğlu, O., & Scanlon, M. C. (2014) · Springer eBooks · doi:10.1007/978-1-4471-6566-8_29
A balanced approach to using organizational patient safety incident data for research
Pozzobon, L. D., Tattersall, A., Tosoni, S., et al. (2025) · Healthcare Management Forum · doi:10.1177/08404704251331179
Applications of the Ergonomics for Healthcare Workers: Systematic Review
Rajput, V., Suri, N. M., Kant, S., et al. (2026) · Design science and innovation · doi:10.1007/978-981-96-4186-4_22
Transforming Healthcare Work Systems Through Human-Centred Ergonomic Innovation
Yusof, M. S., & Wahab, N. S. A. (2020) · The Asian Journal of Professional and Business Studies/The Asian Journal of Professional & Business Studies · doi:10.61688/ajpbs.v1i1.134
“Dul et al. (2012) positioned human factors and ergonomics as a discipline capable of contributing simultaneously to human wellbeing and system performance, while Carayon et al. (2006) established a healthcare specific systems perspective through the SEIPS framework.”
InfluentialZhu, L., Wei, S., An, Y., et al. (2026) · Nursing in Critical Care · doi:10.1111/nicc.70666
“Given the limited comparability of scores derived from different instruments, quantitative synthesis was stratified by measurement instrument, and no overall pooled estimate was generated [11].”
Improving patient safety in Libya: the way forward
Elmontsri, M. (2019) · doi:10.25560/76500
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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