The DOI matches its Crossref record; 49 of the 53 references it cites were found in a registry or an index; none of the 35 sources its claims cite is checked for support yet.
Work system design for patient safety: the SEIPS model
Open accessAbstract
Models and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper we describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described.
Overview
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Claims the paper makes
63 Own interpretation · 26 Sources not found · 9 No full text of the sources · 9 Own result · 4 No basis given
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Tasks, tools, and organization coincide with an issue repeatedly reported by staff concerning the process of obtaining clinical information on patients in a timely fashion.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Likewise, quality and safety issues identified were related to insufficient and potentially inaccurate information then collected because of the last minute nature of these clinical assessments.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
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The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Staff responses to the questionnaire were also associated with various processes (including care processes) and outcomes.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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In the paper
“Staff responses to the questionnaire can be associated with numerous aspects of the work system.29”
What the sources say
- Not matchedcites [29] 29. Carayon P, Gurses AP, Hundt AS, et al. Performance obstacles and facilitators of healthcare providers. In: Korunka C, Hoffmann P, eds. Change and quality in human service work. Munich: Hampp Publishers, 2005:257-76.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“and nesting itself in a model familiar to many health care professionals-namely, Donabedian's quality model.11 12”
What the sources say
- Not matchedcites 11 12
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“As a result, components of the work system (such as the organization or the environment) and their interdependencies may be overlooked or underemphasized.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
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In the paper
“The interactions between the various components ''produce'' different outcomes: performance, safety and health, and quality of working life.”
What the sources say
- Not matchedcites [5][6][7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
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- Not matched
In the paper
“Donabedian's model explicitly links the structure and processes of care to subsequent patient outcomes.”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Assessing patient safety and designing systems that produce safe patient care can be accomplished by using the SEIPS model that integrates Donabedian's structure-processoutcome (SPO) framework and the work system model (fig 1).”
plaindirect- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model builds on this idea by showing how work system design (structure) is linked to patient safety (outcome) through care processes.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- Probably not a substantial claim. 66
- It may state two separate claims as one. 20
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They also emphasized coordination issues related to patient information.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Likewise, it was easier to understand comments on the staff questionnaire concerning the work space.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They commented about the low quality of communication with patients regarding preoperative preparation (for example, understanding of instructions) and postoperative recovery (for example, inconsistencies in providers' instructions).”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, unavailability of patient related information sometimes can lead to cancellations of surgeries on the day they are scheduled.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“A review of the floor plans helped the research team further understand the reasons for these concerns.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Staff offered suggestions to remedy this problem through redesign of forms and changes in policy and job design.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Here staff conveyed the inherent inefficiencies of tracking down information that should have been previously provided.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, concern was expressed by staff regarding the lack of privacy for patients and high noise levels.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This gave us greater insight concerning the expectations for the various positions as well as how each centre was organized according to the various tasks.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“In this case the plans provided an understanding of the work flow and offered a greater appreciation for the confidentiality issues identified during the patient shadowing.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“We suggest that the work system model applied to patient safety complements and expands Donabedian's framework.”
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Changes to any aspect of the work system will, depending on how the change or improvement is designed and implemented, either negatively or positively affect the work and clinical processes and the consequent patient, employee, and organizational outcomes.”
plainconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper may give no reason why it holds.
In the paper
“The discipline of human factors emphasizes interactions between people and their environment that contribute to performance, safety and health, and quality of working life, and the goods or services produced.13 14”
What the sources say
- Not matchedcites 13 14
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“In Donabedian's model, the structure includes the organizational structure (work system model component = organization); the material resources (work system model components = environment, technology/tools); and the human resources (work system model components = care provider, tasks).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Overall, the work system in which care is provided affects both the work and clinical processes, which in turn influence the patient, employee, and organizational outcomes of care.”
plaindirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“our SEIPS model does not highlight any single element of the work system.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“According to the work system model, a person (the person could be a care provider, another employee of a healthcare institution such as a biomedical engineer, a unit clerk, or the patient) performs a range of tasks using various tools and technologies.”
What the sources say
- Not matchedcites [5][6][7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“Donabedian 20 concludes that direct relationships may exist between structure, process and outcome.”
What the sources say
- Not matchedcites [20] 20. Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press, 1980.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
hedgedconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This reflects the fact that most of the focus of the SPO model centres on the providers and their relationship with the processes and outcome(s)-that is, quality is assessed by the way in which care is provided by an individual or care team as well as the outcome of the care.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Donabedian's two other means of assessing quality include evaluating the process(es) of care (how provider tasks and clinical processes are both organized and performed) and evaluating the outcome(s) of care (assessing the clinical results and impacts of and patient satisfaction with the care provided).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The implication is, therefore, that aspects of the structure may be of lesser consequence.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“According to Donabedian's model, poor quality, in turn, results by not following what is defined as the appropriate or correct means of performing a task (poor process).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“In Donabedian's model, however, there is a clear statement that ''we must begin … with the performance of physicians and other health care providers''.19”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
boosted- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“The performance of these tasks occurs within a certain physical environment and under specific organizational conditions.”
What the sources say
- Not matchedcites [5][6][7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is important to recognize that a healthcare work system often includes both healthcare providers and the patient being cared for.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The fact that the SEIPS model explains how the design of a system can impact patients, employees, and the organization has its roots in the theory of healthy work organizations (HWOs).”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The work system model also allows linkage of the various elements of the structure in the SPO model-that is, the organizational structure and material and human resources.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It proposes the work system model as an expansion of the structure by addressing elements of the work system model such as the physical environment, organizational culture and climate, error reporting and analysis, and work design that are so much a part of the current patient safety focus.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model specifies feedback loops from processes to work system and from outcomes to work system.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Any healthcare work system can therefore involve multiple individuals such as healthcare providers and patients.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“However, it has been noted that physician professionalism also fosters a ''culture of blame'' when things go wrong because, if physicians are responsible for the entire medical process, then they are also exclusively to blame for poor quality care.26”
What the sources say
- Not matchedcites [26] 26. Leape LL. Error in medicine. JAMA 1994;272:1851-7.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
hedgeddirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
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In the paper
“Professionals such as physicians, nurses, pharmacists, and other licensed healthcare providers are bound by ethical mandates to serve in their clients' best interests.25”
What the sources say
- Not checked — no full text of the sourcecites [25] 25. ABIM Foundation. ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-6. source
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, a care process can be considered as a series of steps or tasks performed by an individual or a team of individuals using various technologies and tools; the care process may involve various locations, therefore different physical environments.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“A system redesign approach to changing physician behavior may not only be a more effective approach, but may be better accepted by physicians than traditional organizational efforts to improve quality using incentives.27”
What the sources say
- Not checked — no full text of the sourcecites [27] 27. Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health- System Pharm 2002;59:436-46. source
hedgedconditional- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Poor processes and outcomes can be triggers for system redesign: the need would then arise to identify negative work system elements that affect processes and the quality and safety of care, as well as employee and organizational outcomes.”
hedgeddirect- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
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Probably not a substantial claim. It may be too vague to check against evidence.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The patient is also involved in patient care processes and is the ''recipient'' of good or bad outcomes of the care process.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
In the paper
“HWOs are organizations that have both good organizational outcomes and a healthy and safe workforce.31 32”
What the sources say
- Not matchedcites 31 32
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“From this viewpoint, the patient is an ''input'' into the SEIPS model.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Some negative elements in a work system that are hard to change may be overcome by focusing on some other positive elements.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Conversely, patient safety activities place greater emphasis on the system in which practitioners work and less on individual performance.21”
What the sources say
- Not checked — no full text of the sourcecites [21] 21. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43. source
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, the PICC line intervention may not decrease the nurse's workload but add to the workload as more and more patients require PICC line insertion rather than central venous catheter insertions.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Our model emphasizes the linkages between patient outcomes and employee/organizational outcomes.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“In the SEIPS model the individual is at the centre of the work system.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These system redesigns support rather than conflict with the physician's role as a professional.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The implication is that outcomes (both patient and employee/organizational, as proposed by the SEIPS model) are related and that they also are associated with structure aspects of the SPO model.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These feedback loops represent pathways to design or redesign the work system.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The care process is also affected by multiple organizational characteristics such as the need for coordination and collaboration among the healthcare providers involved in the process.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Donabedian's model focuses on care process(es)-that is, how care is provided, delivered and managed.”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
- Not matched
In the paper
“Likewise, a bad outcome is associated with the poor performance of an individual (or a group of individuals).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, a care process can be considered as a series of steps or tasks performed by an individual or a team of individuals using various technologies and tools; the care process may involve various locations, therefore different physical environments.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Firstly, if the individual in the work system is a healthcare provider, tasks performed by the individual often involve the patient-for example, surgical tasks.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Using the SEIPS model with the patient at the centre of the work system model can help to identify deficiencies in the healthcare system that can impair the patient's capacity to receive high quality safe care, and therefore contribute to the design of systems and processes for delivering patient centred care.”
plainconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
In the paper
“Involvement of physicians in the system redesign process is critical to both the success of the system and to physician acceptance of the new system.26”
What the sources say
- Not matchedcites [26] 26. Leape LL. Error in medicine. JAMA 1994;272:1851-7.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model expands the concept of process to include not only care processes but also other processes that support the care process such as maintenance, housekeeping and supply chain management.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“6thers have also emphasized the important relationship between patient outcomes and employee/organizational outcomes.15 33”
What the sources say
- Not matchedcites 15 33
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It can be used proactively to guide system design and hazard analysis, or reactively to guide patient or employee injury investigations.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The design of work systems affects patient safety as well as employee and organizational outcomes.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is descriptive, not prescriptive.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This can be considered as a limitation of the model because it does not provide specific guidance as to the critical elements; but it can also be a strength because the model is generic and adaptable to the particular context or situation.”
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The individual is at the centre of the work system and can be a healthcare provider, a healthcare team, or the patient.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, it provides a framework on how to think about the different aspects of a work system, their interactions, and possible outcomes.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
In the paper
“The professional model assumes that providers have the ultimate authority to define and carry out the core tasks of providing medical care.42”
What the sources say
- Not matchedcites [42] 42. Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Harper & Row, 1970.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
- Not matched
In the paper
“Recognizing potential resistance and obtaining strong support from key opinion leaders 43 is essential to effective implementation of the SEIPS model.”
What the sources say
- Not checked — no full text of the sourcecites [43] 43. Flynn KE, Smith MA, Davis MK. From physician to consumer: the effectiveness of strategies to manage health care utilization. Med Care Res Rev 2002;59:455-81. source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It can also guide patient safety researchers toward developing research questions and understanding what variables to measure for a particular study.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Because the professional status of providers is linked so strongly to their autonomy, they may resist system efforts to manage the process of medical care as infringing on their autonomy and degrading their professional status.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This can be considered as a limitation of the model because it does not provide specific guidance as to the critical elements; but it can also be a strength because the model is generic and adaptable to the particular context or situation.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“We have shown that the SEIPS model can be applied in many different ways to patient safety challenges.”
boosted- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is critical to understand how resistance to a systems approach may limit effective implementation of the SEIPS model in practice.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The design of work systems influences processes which, in turn, affect outcomes.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model is useful for providing a view of the whole system instead of focusing on only one aspect of the work system and treating that aspect in isolation.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They also influence each other.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the citing paper
“Detecting and preventing EHR-related safety concerns is challenging because concerns are often multifaceted, involving not only potentially unsafe technological features of the EHR but also EHR user behaviors, organizational characteristics, and rules and regulations that guide EHR-related activities.”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [27]
In the citing paper
“In addition, conceptual frameworks or models have been developed to incorporate the breadth of technical and non-technical factors into the analysis of EHR safety and effectiveness.21 25 27 32 33”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [27]
In the citing paper
“Another systematic review of the effect of EHR use on the quality of outpatient care came to a similarly negative conclusion.29”
From EHR Safety: The Way Forward to Safe and Effective Systems (2008) · cites this paper as [29]
Citations
Cites
Institute of Medicine (2000) · National Academies Press eBooks · doi:10.17226/9728 · Cited by 14,390
Crossing the Quality Chasm: A New Health System for the 21st Century
Baker, A. (2001) · BMJ · doi:10.1136/bmj.323.7322.1192 · Cited by 10,779
To Err is Human: Building a Safer Health System
Hendee, W. R. (2001) · Journal of Vascular and Interventional Radiology · doi:10.1016/s1051-0443(01)70072-3 · Cited by 10,129
Crossing the Quality Chasm: A New Health System for the 21st Century
Committee on Quality of Health Care in America (2002) · Journal for Healthcare Quality · doi:10.1111/j.1945-1474.2002.tb00463.x · Cited by 8,508
Evaluating the quality of medical care
DONABEDIAN, A. (2005) · The Milbank Quarterly · doi:10.1111/j.1468-0009.2005.00397.x · Cited by 6,102
Donabedian, A. (1988) · JAMA · doi:10.1001/jama.260.12.1743 · Cited by 5,895
Evaluating the Quality of Medical Care
Donabedian, A. (1966) · The Milbank Memorial Fund Quarterly · doi:10.2307/3348969 · Cited by 4,418
Profession of Medicine: A Study of the Sociology of Applied Knowledge.
Clausen, G. T., & Freidson, E. (1971) · American Sociological Review · doi:10.2307/2093843 · Cited by 2,047
Leape, L. L. (1994) · PubMed · Cited by 1,961
The definition of quality and approaches to its assessment
Donabedian, A. (1980) · Health Administration Press eBooks · Cited by 1,749
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Cited by
Sorted by citations
Items 201–300 of 1,789
Barriers and facilitators to recovering from e-prescribing errors in community pharmacies
Abraham, O., Stone, J. A., & Chui, M. A. (2014) · Journal of the American Pharmacists Association · doi:10.1331/japha.2015.13239 · Cited by 51
Jarrar, M., Al‐Bsheish, M., Aldhmadi, B. K., Albaker, W. I., Meri, A., Dauwed, M., & Minai, M. S. (2021) · Healthcare · doi:10.3390/healthcare9111578 · Cited by 58
On the importance of systems thinking when using the ALARP principle for risk management
Langdalen, H., Abrahamsen, E. B., & Selvik, J. T. (2020) · Reliability Engineering & System Safety · doi:10.1016/j.ress.2020.107222 · Cited by 50
Auerbach, M. A., Kessler, D. O., & Patterson, M. (2015) · BMJ Simulation & Technology Enhanced Learning · doi:10.1136/bmjstel-2015-000037 · Cited by 50
Application of participatory ergonomics to the redesign of the family-centred rounds process
Xie, A., Carayon, P., COX, E. D., Cartmill, R. S., Li, Y., Wetterneck, T. B., & Kelly, M. M. (2015) · Ergonomics · doi:10.1080/00140139.2015.1029534 · Cited by 53
Self-citationHuman Factors and Health Information Technology: Current Challenges and Future Directions
Kannampallil, T., & Patel, V. L. (2014) · Yearbook of Medical Informatics · doi:10.15265/iy-2014-0005 · Cited by 48
“The performance inputs represent the work system components - physician and patient, tasks, tools, organizational and external factors [40].”
BackgroundMethodRealyvásquez-Vargas, A., Maldonado-Macías, A. A., García-Alcaráz, J. L., & Blanco‐Fernández, J. (2015) · Procedia Manufacturing · doi:10.1016/j.promfg.2015.07.807 · Cited by 50
Katz, M. J., Gürses, A. P., Tamma, P. D., Cosgrove, S. E., Miller, M. A., & Jump, R. (2017) · Clinical Infectious Diseases · doi:10.1093/cid/cix566 · Cited by 49
Self-citationDesign for patient safety: a systems-based risk identification framework
Simsekler, M. C. E., Ward, J., & Clarkson, P. J. (2018) · Ergonomics · doi:10.1080/00140139.2018.1437224 · Cited by 52
“There are a number of classifications that can be used to categorise patient safety risk sources (Carayon et al., 2006; Rogers, 2002; Runciman et al., 2006).”
BackgroundInfluentialThompson, M. J., Reilly, J., & Valdez, R. S. (2016) · Applied Ergonomics · doi:10.1016/j.apergo.2015.10.010 · Cited by 52
Changing to improve? Organizational change and change-oriented leadership in hospitals
Øygarden, O., Olsen, E., & Mikkelsen, A. (2020) · Journal of Health Organization and Management · doi:10.1108/jhom-09-2019-0280 · Cited by 56
Exploring the turbulent nature of nurses’ workflow
Jennings, B. M., Baernholdt, M., & Hopkinson, S. G. (2022) · Nursing Outlook · doi:10.1016/j.outlook.2022.01.002 · Cited by 47
Pennathur, P. R., Thompson, D., Abernathy, J. H., Martinez, E. A., Pronovost, P. J., Kim, G. R., Bauer, L. C., Lubomski, L. H., Marsteller, J. A., & Gürses, A. P. (2013) · Ergonomics · doi:10.1080/00140139.2012.757655 · Cited by 47
“…organisational structure, physical environment) and the processes (including both clinical and non-clinical/supporting processes) (Gurses et al. 2012) were categorised deductively based on a modification of the systems engineering initiative for patient safety (SEIPS) model (Carayon et al. 2006).”
MethodSelf-citationMultisource Evaluation of Surgeon Behavior Is Associated With Malpractice Claims
Lagoo, J., Berry, W. R., Miller, K., et al. (2018) · Annals of Surgery · doi:10.1097/sla.0000000000002742 · Cited by 47
Reeder, S. C., Manias, E., & Riley, R. (2013) · BMJ Quality & Safety · doi:10.1136/bmjqs-2012-001702 · Cited by 47
Kaba, A., & Barnes, S. (2019) · Advances in Simulation · doi:10.1186/s41077-019-0107-8 · Cited by 46
Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients
Wooldridge, A. R., Carayon, P., Hoonakker, P., Hose, B., Eithun, B. L., Brazelton, T., Ross, J., Kohler, J. E., Kelly, M. M., Dean, S. M., et al. (2020) · Applied Ergonomics · doi:10.1016/j.apergo.2020.103059 · Cited by 49
“Designing and implementing a technology must be done carefully so as not to unbalance the work system (Carayon et al., 2006; Smith & Carayon-Sainfort, 1989).”
BackgroundMethodInfluentialSelf-citationToward a process-level view of distributed healthcare tasks: Medication management as a case study
Werner, N. E., Malkana, S., Gürses, A. P., Leff, B. A., & Arbaje, A. I. (2017) · Applied Ergonomics · doi:10.1016/j.apergo.2017.06.020 · Cited by 49
“…involves the dynamic interaction of multiple system elements (e.g., individuals, tasks, organizational structure, technologies, etc.) (Wilson, 2014; Carayon et al., 2006); 3) has both loosely- and tightly-coupled (Weick,1976) non-linear subprocesses; and 4) occurs across multiple system boundaries…”
BackgroundSelf-citationHuman Factors and Systems Engineering Approach to Patient Safety for Radiotherapy
Rivera, A. J., & Karsh, B. (2008) · International Journal of Radiation Oncology*Biology*Physics · doi:10.1016/j.ijrobp.2007.06.088 · Cited by 47
Self-citationParticipatory design of probability-based decision support tools for in-hospital nurses
Jeffery, A. D., Novak, L. L., Kennedy, B., Dietrich, M. S., & Mion, L. C. (2017) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocx060 · Cited by 46
Work design and patient safety§
Carayon, P., Alvarado, C. J., & Hundt, A. S. (2007) · Theoretical Issues in Ergonomics Science · doi:10.1080/14639220701193157 · Cited by 52
“The field of work design relies on three major areas: ergonomics (or human factors); job stress; job/organizational design (Carayon et al. 2003b, 2006).”
BackgroundMethodInfluentialSelf-citationThe Impact of New Graduate Nurse Transition Programs on Competency Development and Patient Safety
Tyndall, D. E., Firnhaber, G. C., & Scott, E. S. (2018) · Advances in Nursing Science · doi:10.1097/ans.0000000000000217 · Cited by 45
Redwood, R., Knobloch, M. J., Pellegrini, D. C., et al. (2018) · Antimicrobial Resistance and Infection Control · doi:10.1186/s13756-017-0278-9 · Cited by 45
“We used the Systems Engineering Initiative for Patient Safety (SEIPS) model, a framework for understanding structures, processes and outcomes in healthcare to model our focus group questions [12].”
MethodSlater, B., Lawton, R., Armitage, G., Bibby, J., & Wright, J. (2012) · Journal of Continuing Education in the Health Professions · doi:10.1002/chp.21130 · Cited by 44
Medication adherence: staying within the boundaries of safety
Mickelson, R. S., & Holden, R. J. (2017) · Ergonomics · doi:10.1080/00140139.2017.1301574 · Cited by 43
“Final PSFs categories were identified as relating to person(s) (individual or team), task, tool/technology, or organisational, social, or physical context (Carayon et al. 2006; Holden et al. 2013) using the Patient Work System model (Holden, Schubert, and Mickelson 2015), an HFE systems framework.”
MethodBrazil, V. A., & Reedy, G. B. (2024) · Advances in Simulation · doi:10.1186/s41077-024-00291-6 · Cited by 47
“Systems engineers [32, 95], architects [71], design experts [69], healthcare improvement specialists [75, 84, 100], safety science experts [103], institutional ethnog-raphers [35, 82], and many others are key collaborators for translational simulation research, practice and faculty development…”
BackgroundMethodParé, G., Raymond, L., de Guinea, A. O., Poba‐Nzaou, P., Trudel, M.-C., Marsan, J., & Micheneau, T. (2015) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2015.07.005 · Cited by 48
EHR‐related medication errors in two ICUs
Carayon, P., Du, S., Brown, R., Cartmill, R. S., Johnson, M., & Wetterneck, T. B. (2017) · Journal of Healthcare Risk Management · doi:10.1002/jhrm.21259 · Cited by 43
Self-citationUsing observation to better understand the healthcare context
Weston, L. E., Krein, S. L., & Harrod, M. (2021) · Qualitative Research in Medicine & Healthcare · doi:10.4081/qrmh.2021.9821 · Cited by 47
Simulation in urology to train non‐technical skills in ward rounds
Somasundram, K., Spence, H., Colquhoun, A., McIlhenny, C., Biyani, C. S., & Jain, S. (2018) · British Journal of Urology · doi:10.1111/bju.14402 · Cited by 43
Faye, H., Rivera-Rodriguez, A. J., Karsh, B., Hundt, A. S., Baker, C., & Carayon, P. (2010) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(10)36056-9 · Cited by 43
Self-citationParticipatory design of a preliminary safety checklist for general practice
Bowie, P., Ferguson, J., Macleod, M. M., Kennedy, S. A., de Wet, C., McNab, D., Kelly, M., McKay, J., & Atkinson, S. (2015) · British Journal of General Practice · doi:10.3399/bjgp15x684865 · Cited by 43
Strategies for conducting situated studies of technology use in hospitals
BLANDFORD, A. E., Berndt, E., Catchpole, K. C., Furniss, D. J., Mayer, A., Mentis, H. M., O’Kane, A. A., Owen, T., Rajkomar, A., & Randell, R. (2014) · Cognition Technology & Work · doi:10.1007/s10111-014-0318-7 · Cited by 43
“Studies have reported using observational methods such as time study and flow process charting (Carayon et al. 2005b), process-tracing to construct behavioural protocols (Cook and Woods 1996; Seagull and Sanderson 2001; Nemeth et al. 2007), and cognitive task analysis (Cook and Woods 1996).”
BackgroundMethodBarwise, A., Leppin, A., Dong, Y., Huang, C., Pinevich, Y., Herasevich, S., Soleimani, J., Gajic, O., Pickering, B., & Kumbamu, A. (2021) · Journal of Patient Safety · doi:10.1097/pts.0000000000000817 · Cited by 43
Priorities Related to Improving Healthcare Safety Through Simulation
Paige, J. T., Fairbanks, R. J. T., & Gaba, D. M. (2018) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000295 · Cited by 43
Human Factors and Ergonomics in Health Care
Carayon, P., Alyousef, B., & Xie, A. (2012) · Wiley eBooks · doi:10.1002/9781118131350.ch57 · Cited by 48
Self-citationPatient Portals to Support Care Partner Engagement in Adolescent and Adult Populations
Gleason, K. T., Peereboom, D., Wec, A., & Wolff, J. L. (2022) · JAMA Network Open · doi:10.1001/jamanetworkopen.2022.48696 · Cited by 45
A framework to support risk assessment in hospitals
Kaya, G. K., Ward, J., & Clarkson, P. J. (2018) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzy194 · Cited by 41
Realyvásquez-Vargas, A., Maldonado-Macías, A. A., García-Alcaráz, J. L., Cortés-Robles, G., & Blanco‐Fernández, J. (2016) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph13010104 · Cited by 42
Medication Management: The Macrocognitive Workflow of Older Adults With Heart Failure
Mickelson, R. S., Unertl, K. M., & Holden, R. J. (2016) · JMIR Human Factors · doi:10.2196/humanfactors.6338 · Cited by 43
“A limitation of that and other workflow and work system models [45,73,74] has been their vague depiction of process (eg, care vs noncare; cognitive, physical, or social-behavioral).”
BackgroundGürses, A. P., Dietz, A. S., Nowakowski, E., Andonian, J. S., Schiffhauer, M., Billman, C., Abashian, A. M., Trexler, P. A., Osei, P., Benishek, L. E., et al. (2018) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2018.292 · Cited by 42
Self-citationHundt, A. S., Adams, J. A., Schmid, J. A., Musser, L. M., Walker, J. M., Wetterneck, T. B., Douglas, S. V., Paris, B. L., & Carayon, P. (2013) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2012.04.005 · Cited by 40
“Many of these vulnerabilities occur by not considering the work system in which the technology is implemented and are related to the design of the technology and its impact on workflows and processes [5].”
BackgroundSelf-citationUncovering the invisible patient work system through a case study of breast cancer self-management
Gorman, R. K., Wellbeloved-Stone, C. A., & Valdez, R. S. (2018) · Ergonomics · doi:10.1080/00140139.2018.1503339 · Cited by 42
“…a variety of contextual factors, including organization, society, culture, politics, regulation and the economy (National Academies of Science 2011; Carayon et al. 2006; Holden et al. 2013; CONTACT Rupa S. Valdez Rsv9d@virginia.edu Department of Public Health Sciences, University of Virginia, P.O.…”
BackgroundAbraham, O., & Chui, M. A. (2013) · BMJ Quality & Safety · doi:10.1136/bmjqs-2013-001834 · Cited by 42
Russ, A. L., Saleem, J. J., Justice, C. F., Woodward-Hagg, H., Woodbridge, P. A., & Doebbeling, B. N. (2010) · Health Informatics Journal · doi:10.1177/1460458210365981 · Cited by 44
Fabre, V., Secaira, C., Cosgrove, S. E., et al. (2023) · Clinical Infectious Diseases · doi:10.1093/cid/ciad184 · Cited by 41
“Directed content analysis of the interview transcripts was performed focusing on barriers and facilitators of ASP implementation guided by the SEIPS model [6].”
MethodCNA Training Requirements and Resident Care Outcomes in Nursing Homes
Trinkoff, A. M., Storr, C. L., Lerner, N. B., Yang, B. K., & Han, K. (2016) · The Gerontologist · doi:10.1093/geront/gnw049 · Cited by 40
Baubie, K., Shaughnessy, C., Kostiuk, L., Joseph, M. V., Safdar, N., Singh, S. K., Siraj, D. S., Sethi, A. K., & Keating, J. A. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-026193 · Cited by 41
“This framework evaluates the interactions between the people, organisation, tasks, tools/technology and environment of a given work system, allowing for identification of key areas for improvement or intervention.(19) Interviews were conducted in private rooms at the hospital, and were audio recorded after obtaining v…”
BackgroundExploring SEIPS 2.0 as a model for analyzing care transitions across work systems
Werner, N. E., Rutkowski, R. A., Graske, A., Finta, M. K., Sellers, C. R., Seshadri, S., & Shah, M. N. (2020) · Applied Ergonomics · doi:10.1016/j.apergo.2020.103141 · Cited by 40
“As suggested by Carayon (2006), the identification and analysis of cross-boundary system interactions can be used as a way to align work systems (Carayon 2006).”
BackgroundMethodInfluentialApplying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care
Wilson, J. A., Bak, A., & Loveday, H. P. (2017) · American Journal of Infection Control · doi:10.1016/j.ajic.2017.02.019 · Cited by 40
Hemsley, B., Georgiou, A., Hill, S., Rollo, M. E., Steel, J., & Balandin, S. (2015) · Patient Education and Counseling · doi:10.1016/j.pec.2015.10.022 · Cited by 49
“(2006) [20] No Yes Yes No Yes Brown et al.”
BackgroundAddressing Occupational Fatigue in Nurses
Steege, L. M. B., Pinekenstein, B. J., Rainbow, J. G., & Knudsen, É. N. A. (2017) · JONA The Journal of Nursing Administration · doi:10.1097/nna.0000000000000509 · Cited by 40
A Human Factors Engineering Study of the Medication Delivery Process during an Anesthetic
Yang, Y., Rivera, A. J., Fortier, C. R., & Abernathy, J. H. (2016) · Anesthesiology · doi:10.1097/aln.0000000000001040 · Cited by 41
Or, C. K., Holden, R. J., & Valdez, R. S. (2022) · Automation, collaboration, and e-services · doi:10.1007/978-3-031-10788-7_6 · Cited by 50
Pilosof, N. P., Barrett, M. I., Oborn, E., Barkai, G., Pessach, I. M., & Zimlichman, E. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18168391 · Cited by 39
Sociotechnical approaches to workplace safety: Research needs and opportunities
Robertson, M. M., Hettinger, L. J., Waterson, P. E., et al. (2015) · Ergonomics · doi:10.1080/00140139.2015.1011241 · Cited by 39
“…(observability) relationships between system components, including those seemingly remote (physically and/or organisationally) from the local work system, can afford useful insights for identifying hazards before accidents occur, or for understanding potential causal factors when they do.”
BackgroundSelf-citationThe role of hospitals' HRM in shaping clinical performance: a holistic approach
Townsend, K., Lawrence, S. A., & Wilkinson, A. J. (2013) · The International Journal of Human Resource Management · doi:10.1080/09585192.2013.775028 · Cited by 41
“Notably, researchers such as Carayon et al. (2006) argue that other hospital processes (e.g. maintenance, housekeeping, supply chain management) support and influence care processes.”
BackgroundMethodCahill, J., Cullen, P., Anwer, S., Gaynor, K., & Wilson, S. (2020) · Technologies · doi:10.3390/technologies8030040 · Cited by 39
Common predictors of nurse-reported quality of care and patient safety
Stimpfel, A. W., Djukic, M., Brewer, C. S., et al. (2017) · Health Care Management Review · doi:10.1097/hmr.0000000000000155 · Cited by 39
A Systems Approach to Identify Factors Influencing Adverse Drug Events in Nursing Homes
Al‐Jumaili, A. A., & Doucette, W. R. (2018) · Journal of the American Geriatrics Society · doi:10.1111/jgs.15389 · Cited by 38
“In 2006, the Systems Engineering Initiative for Patient Safety (SEIPS) model was developed to explain the influence of the work system (interaction between person and work environment) in a healthcare setting and process on health outcomes.(20) A work system is composed of 5 components: person(s), organization, techno…”
MethodSystems modeling and simulation applications for critical care medicine
Dong, Y., Chbat, N. W., Gupta, A., Hadžikadić, M., & Gajic, O. (2012) · Annals of Intensive Care · doi:10.1186/2110-5820-2-18 · Cited by 38
“The concept of systems understanding of care delivery was first introduced by Donabedian, but has been more recently championed by numerous advocates including patient groups, providers and business experts [50-53].”
BackgroundAnton, N. E., Hornbeck, T., Modlin, S. J., Haque, M. M., Crites, M., & Yu, D. (2021) · PLoS ONE · doi:10.1371/journal.pone.0254077 · Cited by 37
“Findings are summarized as a work system model (Fig 3) by adapting the Systems Engineering Initiative for Patient Safety (SEIPS) model [22, 23].”
MethodAddressing Occupational Fatigue in Nurses
Steege, L. M. B., & Pinekenstein, B. J. (2016) · JONA The Journal of Nursing Administration · doi:10.1097/nna.0000000000000325 · Cited by 40
Human factors in escalating acute ward care: a qualitative evidence synthesis
Ede, J., Petrinic, T., Westgate, V., Darbyshire, J. L., Endacott, R., & Watkinson, P. (2021) · BMJ Open Quality · doi:10.1136/bmjoq-2020-001145 · Cited by 38
(2010) · PubMed · Cited by 38
Development of a primary care physician task list to evaluate clinic visit workflow: Table 1
Wetterneck, T. B., Lapin, J. A., Krueger, D. J., Holman, G. T., Beasley, J. W., & Karsh, B. (2011) · BMJ Quality & Safety · doi:10.1136/bmjqs-2011-000067 · Cited by 38
“The tasks performed by PCPs during patient visits will vary based on the context of the work system, that is, the country, the organisational characteristics, the tools and technologies in place, the clinical environment, the patient population and individual patient characteristics, and physician characteristics.(23)…”
BackgroundMethodSelf-citationUsing Human Factors and Systems Engineering to Evaluate Readmission after Complex Surgery
Acher, A. W., LeCaire, T. J., Hundt, A. S., Greenberg, C. C., Carayon, P., Kind, A., & Weber, S. M. (2015) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2015.06.014 · Cited by 38
“A mixed methods approach was guided by the SEIPS model.(7,8) The 5 elements of the work system as defined by the SEIPS model, namely, People, Tasks, Technology and Tools, Organization, and Environment, framed data collection as well as thematic analysis for investigating aspects of”
Self-citationFurniss, D. J., Masci, P. M., Curzon, P., Mayer, A., & BLANDFORD, A. E. (2014) · Applied Ergonomics · doi:10.1016/j.apergo.2014.05.012 · Cited by 38
“SEIPS (Systems Engineering Initiative for Patient Safety) is a similar model in that it focuses on details of the work system, processes and outcomes (Carayon et al., 2006).”
BackgroundMethodBullock, A. D., & de Jong, P. G. M. (2013) · Wiley eBooks · doi:10.1002/9781118472361.ch11 · Cited by 40
Integrating Electronic Health Records into Clinical Workflow
Lowry, S. Z., Ramaiah, M., Patterson, E. S., Brick, D., Gürses, A. P., Ozok, A. A., Simmons, D., & Gibbons, M. C. (2014) · Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care · doi:10.1177/2327857914031028 · Cited by 37
Self-citationClinician Roles and Responsibilities During Care Transitions of Older Adults
Schoenborn, N. L., Arbaje, A. I., Eubank, K. J., Maynor, K., & Carrese, J. A. (2013) · Journal of the American Geriatrics Society · doi:10.1111/jgs.12084 · Cited by 37
Lesselroth, B. J., Yang, J., McConnachie, J., Brenk, T., & Winterbottom, L. (2011) · BMJ Quality & Safety · doi:10.1136/bmjqs.2010.042689 · Cited by 37
Healthcare team resilience during COVID-19: a qualitative study
Ambrose, J. W., Catchpole, K., Evans, H. L., Nemeth, L. S., Layne, D. M., & Nichols, M. G. (2024) · BMC Health Services Research · doi:10.1186/s12913-024-10895-3 · Cited by 42
“Our model [15] combines the existing Systems Engineering Initiative for Patient Safety (SEIPS) model [16] (version 1), which is based on five domains (organization, person, tasks, technologies, and tools), and environment and the Advanced Team Decision Making Model [17], which includes components…”
MethodDimensions of ecological validity for usability evaluations in clinical settings
van Berkel, N., Clarkson, M. J., Xiao, G., Dursun, E., Allam, M., Davidson, B. R., & BLANDFORD, A. E. (2020) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2020.103553 · Cited by 37
“[16], and elements of the SEIPS model [29, 30].”
BackgroundMedication administration and interruptions in nursing homes: A qualitative observational study
Odberg, K. R., Hansen, B. S., Aase, K., & Wangensteen, S. (2017) · Journal of Clinical Nursing · doi:10.1111/jocn.14138 · Cited by 37
Workspace preferences and non-preferences in Activity-based Flexible Offices: Two case studies
Chafi, M. B., Harder, M., & Danielsson, C. B. (2019) · Applied Ergonomics · doi:10.1016/j.apergo.2019.102971 · Cited by 37
Cánovas-Segura, B., Campos, M., Morales, A., Juárez, J. M., & Palacios, F. (2016) · Progress in Artificial Intelligence · doi:10.1007/s13748-016-0089-x · Cited by 35
Furniss, D. J., Masci, P. M., Curzon, P., Mayer, A., & BLANDFORD, A. E. (2014) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2014.12.006 · Cited by 36
“[51] introduce SEIPS (Systems Engineering Initiative for Patient Safety), which is a broad framework that includes work system components, processes and outcomes.”
MethodImproving outpatient safety through effective electronic communication: a study protocol
Hysong, S. J., Sawhney, M. K., Wilson, L., Sittig, D. F., Esquivel, A., Watford, M., Giardina, T. D., Espadas, D., & Singh, H. (2009) · Implementation Science · doi:10.1186/1748-5908-4-62 · Cited by 34
Li, R., Smith, M. A., Lu, J., Avati, A., Wang, S. X. Y., Teuteberg, W., Shum, K., Hong, G., Seevaratnam, B., Westphal, J., et al. (2022) · NEJM Catalyst · doi:10.1056/cat.21.0457 · Cited by 38
Self-citationHuman Factors and Ergonomics in Health Care and Patient Safety
Carayon, P. (2011) · CRC Press eBooks · doi:10.1201/b11219-8 · Cited by 36
Self-citationHuman Factor in Sustainable Manufacturing
Jasiulewicz–Kaczmarek, M., & Saniuk, A. (2015) · Lecture notes in computer science · doi:10.1007/978-3-319-20687-5_43 · Cited by 36
“The environment is complex and consists of the physical environment (‘things’), the organizational environment (how activities are organized and controlled), and the social environment (other people, culture) [53].”
BackgroundAndonian, J. S., Kazi, S., Therkorn, J., et al. (2019) · Clinical Infectious Diseases · doi:10.1093/cid/ciz618 · Cited by 36
“Interventions addressed various components of the doffing process, including tools/ technology (eg, PPE selection), people (eg, roles, teamwork), task (eg, technical aspects of PPE removal), and environment (eg, doffing room characteristics) [14, 15].”
BackgroundSelf-citationA tailored intervention to improving the quality of intrahospital nursing handover
Bergs, J., Lambrechts, F., Mulleneers, I., Lenaerts, K., Hauquier, C., Proesmans, G., Creemers, S., & Vandijck, D. M. (2017) · International Emergency Nursing · doi:10.1016/j.ienj.2017.07.005 · Cited by 36
Interpretation of Hospital Nurse Fatigue Using Latent Profile Analysis
Drake, D. A., & Steege, L. M. B. (2016) · Advances in Nursing Science · doi:10.1097/ans.0000000000000130 · Cited by 36
The use and usefulness of ICU diaries to support family members of critically ill patients
Mickelson, R. S., Piras, S. E., Brown, L., Carlile, C., Drumright, K., & Boehm, L. M. (2020) · Journal of Critical Care · doi:10.1016/j.jcrc.2020.10.003 · Cited by 37
“0 model to guide data collection and analysis.[9, 10] Healthcare researchers commonly apply the SEIPS 2.”
MethodPharmacogenomic Clinical Decision Support: A Scoping Review
Smith, D. M., Wake, D. T., & Dunnenberger, H. M. (2022) · Clinical Pharmacology & Therapeutics · doi:10.1002/cpt.2711 · Cited by 37
Toward the Development of the Perfect Medical Team: Critical Components for Adaptation
Gregory, M. E., Hughes, A. M., Benishek, L. E., Sonesh, S. C., Lazzara, E. H., Woodard, L., & Salas, E. (2019) · Journal of Patient Safety · doi:10.1097/pts.0000000000000598 · Cited by 37
Gude, W. T., van Engen-Verheul, M. M., van der Veer, S. N., Kemps, H., Jaspers, M., de Keizer, N. F., & Peek, N. B. (2016) · Implementation Science · doi:10.1186/s13012-016-0516-1 · Cited by 37
Goyal, A. A., Glanzman, H., Quinn, M., Tur, K., Singh, S., Winter, S. M., Snyder, A. M., & Chopra, V. (2019) · BMJ Quality & Safety · doi:10.1136/bmjqs-2019-010208 · Cited by 35
Mills, W. L., Pimentel, C. B., Palmer, J. A., Snow, A. L., Wewiorski, N. J., Allen, R. S., & Hartmann, C. W. (2017) · The Gerontologist · doi:10.1093/geront/gnx023 · Cited by 35
Carayon, P., & Salwei, M. E. (2021) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocab002 · Cited by 36
“The report emphasizes a systems approach to clinician burnout in which the technology (eg, electronic health record [EHR]) is one element of a larger sociotechnical (work) system; such a systems approach is key to improving clinician well-being and patient safety.(4) Based on descriptions by four EHR vendors on their…”
BackgroundSelf-citationMorgan, L. J., Flynn, L., Robertson, E. R., New, S., Forde‐Johnston, C., & McCulloch, P. G. (2016) · Journal of Clinical Nursing · doi:10.1111/jocn.13401 · Cited by 35
“It has been accepted that the origins of unsafe healthcare are likely to be bound up with complex system-level issues requiring in-depth analysis of practice (Carayon et al. 2006).”
BackgroundGude, W. T., Roos-Blom, M.-J., van der Veer, S. N., de Jonge, E., Peek, N. B., Dongelmans, D. A., & de Keizer, N. F. (2017) · Implementation Science · doi:10.1186/s13012-017-0594-8 · Cited by 37
“In short, we used the Systems Engineering Initiative for Patient Safety (SEIPS) model [47] to identify the potential barriers in the care structures and processes that could lead to poor performance on each of the indicators.”
MethodRoos-Blom, M.-J., Gude, W. T., de Jonge, E., Spijkstra, J. J., van der Veer, S. N., Peek, N. B., Dongelmans, D. A., & de Keizer, N. F. (2019) · BMJ Quality & Safety · doi:10.1136/bmjqs-2019-009588 · Cited by 36
“40 We identified barriers that could potentially lead to poor performance on any of the four pain management indicators.”
Schutijser, B. C. F. M., Klopotowska, J. E., Jongerden, I. P., Spreeuwenberg, P. M. M., Wagner, C., & de Bruijne, M. C. (2018) · BMJ Open · doi:10.1136/bmjopen-2017-019648 · Cited by 34
Krämer, T., Schneider, A., Spieß, E., Angerer, P., & Weigl, M. (2016) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzw119 · Cited by 36
“Weaknesses within the hospital system which promote errors and poor work quality need to be addressed accordingly [28, 29].”
BackgroundHolden, R. J., Schubert, C. C., Eiland, E. C., Storrow, A. B., Miller, K. F., & Collins, S. P. (2015) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2014.12.031 · Cited by 33
Perry, S. J., Catchpole, K. C., Rivera, A. J., Parker, S. H., & Gosbee, J. W. (2021) · Applied Ergonomics · doi:10.1016/j.apergo.2019.103040 · Cited by 34
“that impact work, (Carayon et al., 2006; Holden et al., 2013) healthcare practitioners simply do not think in terms of identifying clinical work.”
Background
Metadata
- Authors
- Carayon, P., Schoofs Hundt, A., Karsh, B.-T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P.
- Affiliations
- University of Wisconsin–Madison (US)
- Corresponding author
- Carayon, P
- ORCID
- Venue
- Quality in Health Care
- Publisher
- BMJ
- Published
- 2006-12
- Volume
- 15
- Issue
- suppl 1
- Pages
- i50-i58
- ISSN
- 1475-3898 (ISSN-L)
- 1475-3901
- PMC
- PMC2464868
- OpenAlex
- W2163767758
- Semantic Scholar
- d1341354adecf3074cdce8d706ccfec017ac370f
- Cited by
- 1,795
- References
- 53
- Citations by year
- 2026: 199 · 2025: 140 · 2024: 129 · 2023: 122 · 2022: 119 · 2021: 150 · 2020: 132 · 2019: 118 · 2018: 102 · 2017: 93 · 2016: 97 · 2015: 70 · 2014: 77 · 2013: 66 · 2012: 50
- FWCI
- 4.54
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- BMJ Quality & Safety (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Agency for Healthcare Research and Quality (#P20 HS11561-01, P20 HS011561)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Quality and Management
- Social Sciences › Human Factors and Ergonomics › Ergonomics and Human Factors
- Keywords
- work system design, patient safety, SEIPS model, health care system, outpatient surgery, safety culture
- MeSH terms
- Humans, Ergonomics, Models, Theoretical, Quality Assurance, Health Care, Surgicenters, Systems Analysis, Task Performance and Analysis, United States, Outcome Assessment, Health Care, Safety Management, Medical Errors
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-10-11, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-11 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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