The DOI matches its Crossref record; 49 of the 53 references it cites were found in a registry or an index; none of the 35 sources its claims cite is checked for support yet.
Work system design for patient safety: the SEIPS model
Open accessAbstract
Models and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper we describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described.
Overview
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Claims the paper makes
63 Own interpretation · 26 Sources not found · 9 No full text of the sources · 9 Own result · 4 No basis given
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Tasks, tools, and organization coincide with an issue repeatedly reported by staff concerning the process of obtaining clinical information on patients in a timely fashion.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Likewise, quality and safety issues identified were related to insufficient and potentially inaccurate information then collected because of the last minute nature of these clinical assessments.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
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The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Staff responses to the questionnaire were also associated with various processes (including care processes) and outcomes.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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In the paper
“Staff responses to the questionnaire can be associated with numerous aspects of the work system.29”
What the sources say
- Not matchedcites [29] 29. Carayon P, Gurses AP, Hundt AS, et al. Performance obstacles and facilitators of healthcare providers. In: Korunka C, Hoffmann P, eds. Change and quality in human service work. Munich: Hampp Publishers, 2005:257-76.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“and nesting itself in a model familiar to many health care professionals-namely, Donabedian's quality model.11 12”
What the sources say
- Not matchedcites 11 12
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“As a result, components of the work system (such as the organization or the environment) and their interdependencies may be overlooked or underemphasized.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
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In the paper
“The interactions between the various components ''produce'' different outcomes: performance, safety and health, and quality of working life.”
What the sources say
- Not matchedcites [5][6][7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
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- Not matched
In the paper
“Donabedian's model explicitly links the structure and processes of care to subsequent patient outcomes.”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Assessing patient safety and designing systems that produce safe patient care can be accomplished by using the SEIPS model that integrates Donabedian's structure-processoutcome (SPO) framework and the work system model (fig 1).”
plaindirect- Asserted: passes — The authors put it forward as true.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model builds on this idea by showing how work system design (structure) is linked to patient safety (outcome) through care processes.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- Probably not a substantial claim. 66
- It may state two separate claims as one. 20
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They also emphasized coordination issues related to patient information.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“Likewise, it was easier to understand comments on the staff questionnaire concerning the work space.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They commented about the low quality of communication with patients regarding preoperative preparation (for example, understanding of instructions) and postoperative recovery (for example, inconsistencies in providers' instructions).”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, unavailability of patient related information sometimes can lead to cancellations of surgeries on the day they are scheduled.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“A review of the floor plans helped the research team further understand the reasons for these concerns.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Staff offered suggestions to remedy this problem through redesign of forms and changes in policy and job design.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Here staff conveyed the inherent inefficiencies of tracking down information that should have been previously provided.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, concern was expressed by staff regarding the lack of privacy for patients and high noise levels.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This gave us greater insight concerning the expectations for the various positions as well as how each centre was organized according to the various tasks.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
The paper states this without a source or data behind it here, so there is nothing to check it against. The quote shows it is in the paper.
In the paper
“In this case the plans provided an understanding of the work flow and offered a greater appreciation for the confidentiality issues identified during the patient shadowing.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“We suggest that the work system model applied to patient safety complements and expands Donabedian's framework.”
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Changes to any aspect of the work system will, depending on how the change or improvement is designed and implemented, either negatively or positively affect the work and clinical processes and the consequent patient, employee, and organizational outcomes.”
plainconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper may give no reason why it holds.
In the paper
“The discipline of human factors emphasizes interactions between people and their environment that contribute to performance, safety and health, and quality of working life, and the goods or services produced.13 14”
What the sources say
- Not matchedcites 13 14
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“In Donabedian's model, the structure includes the organizational structure (work system model component = organization); the material resources (work system model components = environment, technology/tools); and the human resources (work system model components = care provider, tasks).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Overall, the work system in which care is provided affects both the work and clinical processes, which in turn influence the patient, employee, and organizational outcomes of care.”
plaindirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“our SEIPS model does not highlight any single element of the work system.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“According to the work system model, a person (the person could be a care provider, another employee of a healthcare institution such as a biomedical engineer, a unit clerk, or the patient) performs a range of tasks using various tools and technologies.”
What the sources say
- Not matchedcites [5][6][7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“Donabedian 20 concludes that direct relationships may exist between structure, process and outcome.”
What the sources say
- Not matchedcites [20] 20. Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press, 1980.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
hedgedconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This reflects the fact that most of the focus of the SPO model centres on the providers and their relationship with the processes and outcome(s)-that is, quality is assessed by the way in which care is provided by an individual or care team as well as the outcome of the care.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Donabedian's two other means of assessing quality include evaluating the process(es) of care (how provider tasks and clinical processes are both organized and performed) and evaluating the outcome(s) of care (assessing the clinical results and impacts of and patient satisfaction with the care provided).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The implication is, therefore, that aspects of the structure may be of lesser consequence.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“According to Donabedian's model, poor quality, in turn, results by not following what is defined as the appropriate or correct means of performing a task (poor process).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“In Donabedian's model, however, there is a clear statement that ''we must begin … with the performance of physicians and other health care providers''.19”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
boosted- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“The performance of these tasks occurs within a certain physical environment and under specific organizational conditions.”
What the sources say
- Not matchedcites [5][6][7]
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is important to recognize that a healthcare work system often includes both healthcare providers and the patient being cared for.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The fact that the SEIPS model explains how the design of a system can impact patients, employees, and the organization has its roots in the theory of healthy work organizations (HWOs).”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The work system model also allows linkage of the various elements of the structure in the SPO model-that is, the organizational structure and material and human resources.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It proposes the work system model as an expansion of the structure by addressing elements of the work system model such as the physical environment, organizational culture and climate, error reporting and analysis, and work design that are so much a part of the current patient safety focus.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model specifies feedback loops from processes to work system and from outcomes to work system.”
plaindirect- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Any healthcare work system can therefore involve multiple individuals such as healthcare providers and patients.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim.
In the paper
“However, it has been noted that physician professionalism also fosters a ''culture of blame'' when things go wrong because, if physicians are responsible for the entire medical process, then they are also exclusively to blame for poor quality care.26”
What the sources say
- Not matchedcites [26] 26. Leape LL. Error in medicine. JAMA 1994;272:1851-7.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
hedgeddirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
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In the paper
“Professionals such as physicians, nurses, pharmacists, and other licensed healthcare providers are bound by ethical mandates to serve in their clients' best interests.25”
What the sources say
- Not checked — no full text of the sourcecites [25] 25. ABIM Foundation. ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-6. source
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, a care process can be considered as a series of steps or tasks performed by an individual or a team of individuals using various technologies and tools; the care process may involve various locations, therefore different physical environments.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“A system redesign approach to changing physician behavior may not only be a more effective approach, but may be better accepted by physicians than traditional organizational efforts to improve quality using incentives.27”
What the sources say
- Not checked — no full text of the sourcecites [27] 27. Flynn EA, Barker KN, Pepper GA, et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health- System Pharm 2002;59:436-46. source
hedgedconditional- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Poor processes and outcomes can be triggers for system redesign: the need would then arise to identify negative work system elements that affect processes and the quality and safety of care, as well as employee and organizational outcomes.”
hedgeddirect- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
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Probably not a substantial claim. It may be too vague to check against evidence.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The patient is also involved in patient care processes and is the ''recipient'' of good or bad outcomes of the care process.”
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
In the paper
“HWOs are organizations that have both good organizational outcomes and a healthy and safe workforce.31 32”
What the sources say
- Not matchedcites 31 32
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
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Probably not a substantial claim. It may state two separate claims as one.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“From this viewpoint, the patient is an ''input'' into the SEIPS model.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Some negative elements in a work system that are hard to change may be overcome by focusing on some other positive elements.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Conversely, patient safety activities place greater emphasis on the system in which practitioners work and less on individual performance.21”
What the sources say
- Not checked — no full text of the sourcecites [21] 21. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43. source
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, the PICC line intervention may not decrease the nurse's workload but add to the workload as more and more patients require PICC line insertion rather than central venous catheter insertions.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Our model emphasizes the linkages between patient outcomes and employee/organizational outcomes.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“In the SEIPS model the individual is at the centre of the work system.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These system redesigns support rather than conflict with the physician's role as a professional.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The implication is that outcomes (both patient and employee/organizational, as proposed by the SEIPS model) are related and that they also are associated with structure aspects of the SPO model.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These feedback loops represent pathways to design or redesign the work system.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The care process is also affected by multiple organizational characteristics such as the need for coordination and collaboration among the healthcare providers involved in the process.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“Donabedian's model focuses on care process(es)-that is, how care is provided, delivered and managed.”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
- Not matched
In the paper
“Likewise, a bad outcome is associated with the poor performance of an individual (or a group of individuals).”
What the sources say
- Not matchedcites [19] 19. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For instance, a care process can be considered as a series of steps or tasks performed by an individual or a team of individuals using various technologies and tools; the care process may involve various locations, therefore different physical environments.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Firstly, if the individual in the work system is a healthcare provider, tasks performed by the individual often involve the patient-for example, surgical tasks.”
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Using the SEIPS model with the patient at the centre of the work system model can help to identify deficiencies in the healthcare system that can impair the patient's capacity to receive high quality safe care, and therefore contribute to the design of systems and processes for delivering patient centred care.”
plainconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
In the paper
“Involvement of physicians in the system redesign process is critical to both the success of the system and to physician acceptance of the new system.26”
What the sources say
- Not matchedcites [26] 26. Leape LL. Error in medicine. JAMA 1994;272:1851-7.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model expands the concept of process to include not only care processes but also other processes that support the care process such as maintenance, housekeeping and supply chain management.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“6thers have also emphasized the important relationship between patient outcomes and employee/organizational outcomes.15 33”
What the sources say
- Not matchedcites 15 33
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
- Not matched
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It can be used proactively to guide system design and hazard analysis, or reactively to guide patient or employee injury investigations.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The design of work systems affects patient safety as well as employee and organizational outcomes.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is descriptive, not prescriptive.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This can be considered as a limitation of the model because it does not provide specific guidance as to the critical elements; but it can also be a strength because the model is generic and adaptable to the particular context or situation.”
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The individual is at the centre of the work system and can be a healthcare provider, a healthcare team, or the patient.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, it provides a framework on how to think about the different aspects of a work system, their interactions, and possible outcomes.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
In the paper
“The professional model assumes that providers have the ultimate authority to define and carry out the core tasks of providing medical care.42”
What the sources say
- Not matchedcites [42] 42. Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Harper & Row, 1970.
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
- Not matched
In the paper
“Recognizing potential resistance and obtaining strong support from key opinion leaders 43 is essential to effective implementation of the SEIPS model.”
What the sources say
- Not checked — no full text of the sourcecites [43] 43. Flynn KE, Smith MA, Davis MK. From physician to consumer: the effectiveness of strategies to manage health care utilization. Med Care Res Rev 2002;59:455-81. source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It can also guide patient safety researchers toward developing research questions and understanding what variables to measure for a particular study.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Because the professional status of providers is linked so strongly to their autonomy, they may resist system efforts to manage the process of medical care as infringing on their autonomy and degrading their professional status.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This can be considered as a limitation of the model because it does not provide specific guidance as to the critical elements; but it can also be a strength because the model is generic and adaptable to the particular context or situation.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“We have shown that the SEIPS model can be applied in many different ways to patient safety challenges.”
boosted- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“It is critical to understand how resistance to a systems approach may limit effective implementation of the SEIPS model in practice.”
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The design of work systems influences processes which, in turn, affect outcomes.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The SEIPS model is useful for providing a view of the whole system instead of focusing on only one aspect of the work system and treating that aspect in isolation.”
plain- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“They also influence each other.”
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the citing paper
“Detecting and preventing EHR-related safety concerns is challenging because concerns are often multifaceted, involving not only potentially unsafe technological features of the EHR but also EHR user behaviors, organizational characteristics, and rules and regulations that guide EHR-related activities.”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [27]
In the citing paper
“In addition, conceptual frameworks or models have been developed to incorporate the breadth of technical and non-technical factors into the analysis of EHR safety and effectiveness.21 25 27 32 33”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [27]
In the citing paper
“Another systematic review of the effect of EHR use on the quality of outpatient care came to a similarly negative conclusion.29”
From EHR Safety: The Way Forward to Safe and Effective Systems (2008) · cites this paper as [29]
Citations
Cites
Institute of Medicine (2000) · National Academies Press eBooks · doi:10.17226/9728 · Cited by 14,390
Crossing the Quality Chasm: A New Health System for the 21st Century
Baker, A. (2001) · BMJ · doi:10.1136/bmj.323.7322.1192 · Cited by 10,779
To Err is Human: Building a Safer Health System
Hendee, W. R. (2001) · Journal of Vascular and Interventional Radiology · doi:10.1016/s1051-0443(01)70072-3 · Cited by 10,129
Crossing the Quality Chasm: A New Health System for the 21st Century
Committee on Quality of Health Care in America (2002) · Journal for Healthcare Quality · doi:10.1111/j.1945-1474.2002.tb00463.x · Cited by 8,508
Evaluating the quality of medical care
DONABEDIAN, A. (2005) · The Milbank Quarterly · doi:10.1111/j.1468-0009.2005.00397.x · Cited by 6,102
Donabedian, A. (1988) · JAMA · doi:10.1001/jama.260.12.1743 · Cited by 5,895
Evaluating the Quality of Medical Care
Donabedian, A. (1966) · The Milbank Memorial Fund Quarterly · doi:10.2307/3348969 · Cited by 4,418
Profession of Medicine: A Study of the Sociology of Applied Knowledge.
Clausen, G. T., & Freidson, E. (1971) · American Sociological Review · doi:10.2307/2093843 · Cited by 2,047
Leape, L. L. (1994) · PubMed · Cited by 1,961
The definition of quality and approaches to its assessment
Donabedian, A. (1980) · Health Administration Press eBooks · Cited by 1,749
Research works printed but not linked: 2
- [8]8. Reason J. Human error. Cambridge: Cambridge University Press, 1990.
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Cited by
Sorted by citations
Items 501–600 of 1,789
Improving Patient Safety in the Patient Journey: Contributions from Human Factors Engineering
Carayon, P., & Wooldridge, A. R. (2019) · Women in engineering and science · doi:10.1007/978-3-030-11866-2_12 · Cited by 23
Self-citationValmadrid, L. C., Schwei, R. J., Maginot, E. R., & Pulia, M. S. (2020) · American Journal of Infection Control · doi:10.1016/j.ajic.2020.07.009 · Cited by 18
“We developed a semi-structured interview guide comprised of open-ended questions and structured items informed by the Systems Engineering Initiative for Patient Safety (SEIPS) model.(31,32) The SEIPS model was selected as it was designed to capture all elements of a health care work system or process that can impact q…”
Enticott, J., Jeffcott, S. A., Ibrahim, J., Wood, E. M., Cole-Sinclair, M. F., Fitzgerald, M., Cameron, P. A., & Phillips, L. E. (2012) · Transfusion · doi:10.1111/j.1537-2995.2012.03648.x · Cited by 17
Reducing wrong intraocular lens implants in cataract surgery
Loh, H. P., de Korne, D. F., Chee, S.-P., & Mathur, R. (2017) · International Journal of Health Care Quality Assurance · doi:10.1108/ijhcqa-06-2016-0095 · Cited by 17
Pickup, L., Lang, A. R., Atkinson, S., et al. (2017) · Ergonomics · doi:10.1080/00140139.2017.1306632 · Cited by 17
“The findings were thematically analysed using the Systems Engineering Initiative for Patient Safety model (Carayon et al. 2006) and variability analysed using the Functional Resonance Analysis Method (FRAM; Hollnagel 2012).”
MethodUK rail workers' perceptions of accident risk factors: An exploratory study
Morgan, J. I., Abbott, R. L., Furness, P. J., & Ramsay, J. E. (2016) · International Journal of Industrial Ergonomics · doi:10.1016/j.ergon.2016.08.003 · Cited by 21
“In a number of high-risk domains, including healthcare, specific frameworks for RAIL WORKER ACCIDENT RISK FACTORS studying work systems have been proposed (e.g. System Engineering Initiative for Patient Safety, Carayon et al. 2006; Yorkshire Contributory Factors Framework, Lawton et al., 2012b).”
Lumley, C., Ellis, A., Ritchings, S., Venes, T., & Ede, J. (2020) · Nursing in Critical Care · doi:10.1111/nicc.12514 · Cited by 18
“The Systems Engineering Initiative for Patient Safety (SEIPS) human factors model potentially offers a more comprehensive framework by focusing on health care structures, relationships, and processes.(7) It consists of five key domains: person, task, tools and technology, environment, and organization.”
BackgroundWenderott, K., Krups, J., Weigl, M., & Wooldridge, A. R. (2025) · Journal of Medical Internet Research · doi:10.2196/63649 · Cited by 26
“The axes identified in our ENA can be associated with work system elements of the SEIPS model [17].”
InfluentialA work system analysis of the medication administration process in a Norwegian nursing home ward
Odberg, K. R., Hansen, B. S., Aase, K., & Wangensteen, S. (2020) · Applied Ergonomics · doi:10.1016/j.apergo.2020.103100 · Cited by 17
Probst, M. A., Dayan, P. S., Raja, A. S., Slovis, B. H., Yadav, K., Lam, S. H. F., Shapiro, J. S., Farris, C. A., Babcock, C. I., Griffey, R. T., et al. (2015) · Academic Emergency Medicine · doi:10.1111/acem.12830 · Cited by 17
Valdez, R. S., Lunsford, C. D., Bae, J., Letzkus, L., & Keim‐Malpass, J. (2019) · JMIR Research Protocols · doi:10.2196/14810 · Cited by 17
A Human Factors Approach to Surgical Patient Safety
Cohen, T., Gewertz, B. L., & Shouhed, D. (2020) · Surgical Clinics of North America · doi:10.1016/j.suc.2020.09.006 · Cited by 17
Danesh, M. K., Garosi, E., Mazloumi, A., et al. (2020) · Work · doi:10.3233/wor-203199 · Cited by 17
Improving the handover and transport of critically ill pediatric patients
VanGraafeiland, B., Foronda, C. L., Vanderwagen, S., et al. (2018) · Journal of Clinical Nursing · doi:10.1111/jocn.14627 · Cited by 17
“This model was chosen due to its assimilation of human factor system tactics to patient safety research, analysis and improvement (Carayon et al., 2006).”
BackgroundMethodWeigl, M., Lifschitz, M., & Dodt, C. (2025) · European Journal of Emergency Medicine · doi:10.1097/mej.0000000000001159 · Cited by 17
Asan, O., Chiou, E. K., & Montague, E. N. H. (2014) · International Journal of Industrial Ergonomics · doi:10.1016/j.ergon.2014.04.004 · Cited by 16
“In healthcare, this is particularly important because work outcomes have been tied to patient outcomes that are often used as measures of health system improvement (Carayon et al., 2006).”
BackgroundAdvanced Medical Simulation Applications for Emergency Medicine Microsystems Evaluation and Training
Kobayashi, L., Overly, F. L., Fairbanks, R. J. T., et al. (2008) · Academic Emergency Medicine · doi:10.1111/j.1553-2712.2008.00247.x · Cited by 16
Rhee, C., Phelps, M. E., Meyer, B., & Reed, W. G. (2016) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/s1553-7250(16)42060-x · Cited by 18
Kalender, Z. T., Tozan, H., & Vayvay, Ö. (2020) · Healthcare · doi:10.3390/healthcare8030265 · Cited by 16
“[23] stated that most errors and inefficiencies in patient care arise not from the solitary actions of individuals, but from the conflicting, incomplete, or sub-optimal systems of which they are a part and with which they interact.”
BackgroundBowditch, L., Molloy, C., King, B., Abedi, M., Jackson, S., Bierbaum, M., Yu, Y., Raggett, L., Salmon, P., Braithwaite, J., et al. (2026) · BMJ Quality & Safety · doi:10.1136/bmjqs-2025-019063 · Cited by 16
“These more recent versions of SEIPS reflect a sociotechnical systems approach to the patient journey 41 and posit that six elements make up any work situation: the people; the tasks; the tools; the physical environment; the organisation; and the external environment.”
InfluentialCoons, J. C., Patel, R., Coley, K. C., & Empey, P. E. (2019) · Journal of the American Pharmacists Association · doi:10.1016/j.japh.2019.01.001 · Cited by 21
Savoy, A., Khazvand, S., Mathew, A., Gilmore, A. M., Cottingham, E. M., Sangani, A., Weiner, M., & Damush, T. M. (2023) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2023.105265 · Cited by 17
Creating a Highly Reliable Neonatal Intensive Care Unit Through Safer Systems of Care
Panagos, P. G., & Pearlman, S. A. (2017) · Clinics in Perinatology · doi:10.1016/j.clp.2017.05.006 · Cited by 16
Wooldridge, A. R., Carayon, P., Hoonakker, P., Hose, B., Shaffer, D. W., Brazelton, T., Eithun, B. L., Rusy, D. A., Ross, J., Kohler, J. E., et al. (2022) · Human Factors The Journal of the Human Factors and Ergonomics Society · doi:10.1177/00187208221086342 · Cited by 17
“The work system model is integrated in the Systems Engineering Initiative for Patient Safety (SEIPS) 3.0 model, used to analyze, model and improve both patient and worker outcomes (Carayon et al., 2006, 2014, 2020).”
BackgroundMethodInfluentialSelf-citationDevelopment of a Model for Video-Assisted Postoperative Team Debriefing
van Dalen, A. S. H. M., van Haperen, M., Swinkels, J. A., Grantcharov, T., & Schijven, M. P. (2020) · Journal of Surgical Research · doi:10.1016/j.jss.2020.07.065 · Cited by 17
Training Nontechnical Skills in Ward Rounds to Improve Team Performance
Spence, H., Somasundram, K., Biyani, C. S., & Jain, S. (2020) · Journal of surgical education · doi:10.1016/j.jsurg.2020.02.012 · Cited by 16
Risk factors associated with medication ordering errors
Abraham, J., Galanter, W., Touchette, D. R., Xia, Y., Holzer, K. J., Leung, V., & Kannampallil, T. (2020) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocaa264 · Cited by 16
“To further investigate the risk factors to medication ordering,(5,23) interview questions were based on the Systems Engineering Initiative for Patient Safety (SEIPS) model.(24) The SEIPS model helps elucidate the elements of the medication ordering work system, including people involved in medication ordering (eg, cli…”
MethodHolden, R. J., Brown, R., Scanlon, M. C., Rivera, A. J., & Karsh, B. (2014) · International Journal of Industrial Ergonomics · doi:10.1016/j.ergon.2014.04.003 · Cited by 18
Self-citationCare transition of trauma patients: Processes with articulation work before and after handoff
Wooldridge, A. R., Carayon, P., Hoonakker, P., Hose, B., Schroeer, K., Brazelton, T., Eithun, B. L., Rusy, D. A., Ross, J., Kohler, J. E., et al. (2021) · Applied Ergonomics · doi:10.1016/j.apergo.2021.103606 · Cited by 16
Self-citationAn evidence synthesis on perioperative Handoffs: A call for balanced sociotechnical solutions
Abraham, J., Duffy, C. C., Kandasamy, M., et al. (2023) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2023.105038 · Cited by 16
Simulation-based User-centered Design: An Approach to Device Development during COVID-19
Colman, N., Saldaña, C., Craig, K., et al. (2021) · Pediatric Quality and Safety · doi:10.1097/pq9.0000000000000427 · Cited by 16
Real, K. J., Bell, S., Williams, M. V., Latham, B., Talari, P., & Li, J. (2020) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2020.04.005 · Cited by 16
Knobloch, M. J., Thomas, K. V., Musuuza, J., & Safdar, N. (2019) · American Journal of Infection Control · doi:10.1016/j.ajic.2018.12.017 · Cited by 17
Effects of environmental distractors on nurse emergency triage accuracy: a pilot study protocol
Delmas, P., Fiorentino, A., Antonini, M., Vuilleumier, S., Stotzer, G., Kollbrunner, A., Jaccard, D., Hulaas, J., Rutschmann, O., Simon, J., et al. (2020) · Pilot and Feasibility Studies · doi:10.1186/s40814-020-00717-8 · Cited by 16
Schulz-Quach, C., Lyver, B., Reynolds, C., Hanagan, T., Haines, J., Shannon, J. P., Pozzobon, L. D., Sarraf, Y., Sabbah, S., Ensafi, S., et al. (2025) · BMC Emergency Medicine · doi:10.1186/s12873-024-01144-1 · Cited by 26
“QI projects in patient and staff safety often focus on the three categories derived from Donabedian’s Structure-Process-Outcome (SPO) model [54]; however, this approach omits a focus on the ‘human factor’ within the structure component and the individuals involved in the processes including…”
Discovering the barriers to efficient robotic operating room turnover time: perceptions vs. reality
Cohen, T., Anger, J. T., Shamash, K., et al. (2020) · Journal of Robotic Surgery · doi:10.1007/s11701-020-01045-y · Cited by 16
Assessment of Work Conditions in a Production Enterprise—A Case Study
Tutak, M., Brodny, J., & Dobrowolska, M. (2020) · Sustainability · doi:10.3390/su12135390 · Cited by 16
Improving the Experience of Providing Care in Community-Based Pharmacies
Schommer, J. C., Lee, S., Gaither, C. A., Álvarez, N. A., & Shaughnessy, A. M. (2022) · Pharmacy · doi:10.3390/pharmacy10040067 · Cited by 18
Knowledge mapping analysis of safety ergonomics: a bibliometric study
Ji, W., Liu, H., Pan, K., et al. (2023) · Ergonomics · doi:10.1080/00140139.2023.2223788 · Cited by 15
“Carayon et al. (2006) proposed the SEIPS model in 2006 and described practical applications of the SEIPS model in outpatient surgery.”
BackgroundMethodLeveraging the Science of Teamwork to Sustain Handoff Improvements in Cardiovascular Surgery
Keebler, J. R., Lynch, I. P., Ngo, F., Phelps, E., Huang, N. R., Guttman, O. T., Preble, R. G., Minhajuddin, A., Gamez, N., Wanat-Hawthorne, A., et al. (2023) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2023.05.006 · Cited by 15
Orenstein, E. W., Yun, K., Warden, C., Westerhaus, M., Mirth, M. G., Karavite, D., Mamo, B., Sundar, K. G., & Michel, J. J. (2019) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocz124 · Cited by 15
Yang, Y., & Rivera, A. J. (2015) · Health Policy and Technology · doi:10.1016/j.hlpt.2015.08.003 · Cited by 15
“A STS approach, such as macroergonomics, considers the compatibility of system inputs within the work system: people, tools and technology, tasks, physical environment, and organization elements [35]; and focuses on the joint optimization of the social and technical subsystems [36].”
MethodNascimento, A., & Falzon, P. (2011) · Applied Ergonomics · doi:10.1016/j.apergo.2011.11.011 · Cited by 15
The social network paradigm and applications in pharmacy.
Kjos, A. L., Worley, M., & Schommer, J. (2013) · Research in Social and Administrative Pharmacy · doi:10.1016/j.sapharm.2012.05.015 · Cited by 12
The Role of Simulation in Improving Patient Safety
Auerbach, M. A., Stone, K. P., & Patterson, M. (2016) · Comprehensive healthcare simulation · doi:10.1007/978-3-319-24187-6_5 · Cited by 16
Mort, E. A., Bruckel, J., Donelan, K., et al. (2016) · American Journal of Medical Quality · doi:10.1177/1062860616673709 · Cited by 15
Bongiovanni, I., & Newton, C. J. (2018) · Risk Analysis · doi:10.1111/risa.13238 · Cited by 15
“At an initial stage, decisions made at the managerial level can create the conditions for organizational controls to be bypassed (Carayon et al., 2006; Smith, 1990a, 1990b, 1995).”
BackgroundHignett, S. M., Wolf, L., Taylor, E., et al. (2015) · Human Factors The Journal of the Human Factors and Ergonomics Society · doi:10.1177/0018720815593642 · Cited by 15
“…offers a new HFE integration model (e.g., work system in Systems Engineering Initiative for Patient Safety [SEIPS] model with “person” in the center; Carayon et al., 2006; Holden et al., 2013) by describing the system elements in terms of the level of flexibility or transience (duration of…”
MethodSmith, M. A., Nordby, P., Yu, M., & Jaffery, J. B. (2019) · Applied Ergonomics · doi:10.1016/j.apergo.2019.103023 · Cited by 15
Self-citationSafe use of hospital information systems: an evaluation model based on a sociotechnical perspective
Salahuddin, L. B., Ismail, Z., Ikram, R. R. R., Hashim, U. R., Idris, A., Ismail, N. H., Hassan, N. H., & Rahim, F. A. (2019) · Behaviour and Information Technology · doi:10.1080/0144929x.2019.1597164 · Cited by 14
“Person refers to the characteristics or conditions of a single or group of healthcare practitioners performing patient care-related tasks (Carayon et al. 2006).”
BackgroundMethodInfluentialA text mining analysis of medication quality related event reports from community pharmacies
Lester, C. A., Kessler, J. M., Modisett, T., & Chui, M. A. (2018) · Research in Social and Administrative Pharmacy · doi:10.1016/j.sapharm.2018.09.013 · Cited by 20
“12,13 The framework depicts that prescriptions have certain characteristics (e.g., new/refill, electronic/phone) and the pharmacy has existing prevention strategies in place.”
BackgroundFurniss, D. J., Mayer, A., Franklin, B. D., & BLANDFORD, A. E. (2019) · Safety Science · doi:10.1016/j.ssci.2019.06.006 · Cited by 15
Wang, J., Simmons, S. F., Maxwell, C. A., Schlundt, D. G., & Mion, L. C. (2018) · Journal of Community Health Nursing · doi:10.1080/07370016.2018.1475799 · Cited by 15
“Conceptual model adapted from the SEIPS model (Carayon et al., 2006; Holden et al., 2013).”
MethodInfection prevention and control in the medical imaging environment: a scoping review
Jimenez, Y. A., & Lewis, S. J. (2023) · Insights into Imaging · doi:10.1186/s13244-023-01470-1 · Cited by 18
“As such, the Systems Engineering Initiative for Patient Safety (SEIPS) model [12] provides a suitable framework for IPC practice descriptions in medical imaging.”
BackgroundMethodMcDonald, K. M., Su, G., Lisker, S., Patterson, E. S., & Sarkar, U. (2017) · Implementation Science · doi:10.1186/s13012-017-0609-5 · Cited by 15
Medication Errors in the Intensive Care Unit
Frith, K. H. (2013) · AACN Advanced Critical Care · doi:10.4037/nci.0b013e3182a8b516 · Cited by 15
Human-centered design of team health IT for pediatric trauma care transitions
Carayon, P., Hose, B., Wooldridge, A. R., Brazelton, T., Dean, S. M., Eithun, B. L., Kelly, M. M., Kohler, J. E., Ross, J., Rusy, D. A., et al. (2022) · International Journal of Medical Informatics · doi:10.1016/j.ijmedinf.2022.104727 · Cited by 15
Self-citationBrunner, J., Cannedy, S., McCoy, M., Hamilton, A. B., & Shelton, J. B. (2023) · Journal of General Internal Medicine · doi:10.1007/s11606-023-08280-7 · Cited by 20
English, M., Ogola, M., Aluvaala, J., Gicheha, E., Irimu, G., McKnight, J., & Vincent, C. A. (2020) · Archives of Disease in Childhood · doi:10.1136/archdischild-2020-320630 · Cited by 16
Impact of disruptions on anaesthetic workflow during anaesthesia induction and patient positioning
Al‐Hakim, L., Arora, S., & Sevdalis, N. (2016) · European Journal of Anaesthesiology · doi:10.1097/eja.0000000000000484 · Cited by 15
Wallin, A., Ringdal, M., Ahlberg, K., et al. (2022) · Scandinavian Journal of Caring Sciences · doi:10.1111/scs.13124 · Cited by 15
Carayon, P., Kleinschmidt, P. C., Hose, B., & Salwei, M. E. (2020) · Springer eBooks · doi:10.1007/978-3-030-59403-9_7 · Cited by 22
Self-citationLundgren, D., Bravell, M. E., Börjesson, U., & Kåreholt, I. (2019) · Gerontology and Geriatric Medicine · doi:10.1177/2333721419841245 · Cited by 19
“These variations might affect the need for different collaboration and coordination among the care providers involved in the process (Carayon et al., 2006).”
BackgroundMethodInfluentialChandra, C., Hudson, A., Alohan, D. I., Young, H. N., & Crawford, N. D. (2024) · Current HIV/AIDS Reports · doi:10.1007/s11904-024-00700-5 · Cited by 16
“…science frameworks such as the Systems Engineering Initiative for Patient Safety (SEIPS) may be employed or integrated with more frequently used implementation science frameworks to ensure that implementation of PrEP in pharmacies equally values patient safety, cost, and workflow models [47].”
McLean, K. J., Haas, M. F., Koenig, J., Horvath, M., Vigil, M., Werner, N. E., & Bishop, L. (2024) · Autism · doi:10.1177/13623613241236380 · Cited by 21
“Having the patient at the center of our work system model helped us to identify deficiencies in the healthcare system that may impair an autistic adult’s capacity to receive quality care (Carayon et al., 2006).”
BackgroundMethodInfluentialYao, X., Paulson, M. R., Maniaci, M. J., Dunn, A. N., Nelson, C. R., Behnken, E., Hart, M. S., Sangaralingham, L. R., Inselman, S. A., Lampman, M. A., et al. (2022) · Trials · doi:10.1186/s13063-022-06430-6 · Cited by 17
“We will use the Systems Engineering Initiative for Patient Safety model [15] and the Consolidated Framework for Implementation Research [16, 17] to inform the qualitative data collection and analysis.”
MethodHuman factors and ergonomics for primary care
Bowie, P., & Jeffcott, S. A. (2016) · Education for Primary Care · doi:10.1080/14739879.2016.1152658 · Cited by 15
Yang, Y., & Asan, O. (2016) · Journal of Innovation in Health Informatics · doi:10.14236/jhi.v23i1.185 · Cited by 19
“52 Besides that, based on the Systems Engineering Initiative for Patient Safety model, 32 research has shown multiple system factors associated with different work sys-tem elements to influence doctors’ decision to share or not to share the screen.”
BackgroundMethodUtilizing the SEIPS model to guide hand hygiene interventions at a tertiary hospital in Ethiopia
Berman, L. R., Kavalier, M., Gelana, B., Tesfaw, G., Siraj, D. S., Shirley, D. K., & Yilma, D. (2021) · PLoS ONE · doi:10.1371/journal.pone.0258662 · Cited by 14
Samaan, D., & Tursunbayeva, A. (2024) · International Journal of Public Sector Management · doi:10.1108/ijpsm-10-2023-0311 · Cited by 15
Smith, M. W., Brown, C. R., Virani, S. S., Weir, C. R., Petersen, L. A., Kelly, N., Akeroyd, J. M., & Garvin, J. H. (2018) · Applied Clinical Informatics · doi:10.1055/s-0038-1660849 · Cited by 13
Self-citationMedication errors, handoff processes and information quality
Chircu, A. M., Gogan, J. L., Boss, S. R., & Baxter, R. J. (2013) · Business Process Management Journal · doi:10.1108/14637151311308286 · Cited by 16
“We identified the main medication administration activities in an end-to-end hospitalization process and organized these into three sub-processes: patient admission, hospitalization, and discharge (Bayley et al., 2005; Carayon et al., 2006).”
BackgroundGarduño-López, A. L., Acosta-Nava, V. M., Garcés, L. C., Rascón-Martínez, D. M., Cuéllar-Guzmán, L. F., Flores-Villanueva, M. E., Villegas-Sotelo, E., Carrillo-Torres, O., Sámano, H. V., Calderón-Vidal, M., et al. (2021) · Journal of Pain Research · doi:10.2147/jpr.s282850 · Cited by 14
The Work and Work Systems of Patients: A New Frontier for Macroergonomics in Health Care
Valdez, R. S., Holden, R. J., Hundt, A. S., et al. (2014) · Proceedings of the Human Factors and Ergonomics Society Annual Meeting · doi:10.1177/1541931214581165 · Cited by 14
“SEIPS 2.0 specifies high-level categories of macroergonomic factors influencing both professional and patient (and family) performance but not specific subcategories.”
MethodInfluentialSelf-citationRisk management in the healthcare safety management system
Voskanyan, Y., Shikina, I. B., Kidalov, F., Рудольфович, Д. Д., & Abrosimova, T. (2021) · Journal of Digital Science · doi:10.33847/2686-8296.3.1_4 · Cited by 15
Keller, S. C., Pau, S., Salinas, A. B., Oladapo-Shittu, O., Cosgrove, S. E., Lewis‐Cherry, R., Vecchio-Pagán, B., Osei, P., Gürses, A. P., Rock, C., et al. (2021) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2021.154 · Cited by 15
Self-citationUse of Electronic Health Records by Nurses for Symptom Management in Inpatient Settings
Ozkaynak, M., Reeder, B., Hoffecker, L., Makic, M. B. F., & Sousa, K. H. (2017) · CIN Computers Informatics Nursing · doi:10.1097/cin.0000000000000329 · Cited by 14
“These interventions (individual, organization, task, and technologyrelated factors, and the interplay among them) could better support nurses’ work and improve symptom management and documentation.(36) In addition, user-centered design of EHR systems is needed.”
BackgroundSchmajuk, G., Tonner, C., Trupin, L. S., et al. (2017) · Medicine · doi:10.1097/md.0000000000006528 · Cited by 14
Göransson, K. E., Drennan, J., Mainz, H., Skov, N. F., Amritzer, M. A., Berg, L. M., Andersen, K. V., & Lisby, M. (2024) · International Journal of Nursing Studies Advances · doi:10.1016/j.ijnsa.2024.100270 · Cited by 15
“This can be described as an intricate network of health care providers, patients, policies and technologies that interact and adapt, often leading to unpredictable outcomes (Carayon et al., 2006).”
What should we do when traditional research fails?
Murray, D. (2017) · Anaesthesia · doi:10.1111/anae.13935 · Cited by 14
“Human factors and ergonomics describe the interactions between all aspects of the wider workspace: people; the physical environment; tools and technology; and the processes of care that we engage with in the delivery of healthcare [26].”
BackgroundLesselroth, B., Adams, K. A., Church, V., Tallett, S., Russ, Y., Wiedrick, J. T., Forsberg, C. W., & Dorr, D. A. (2018) · Applied Clinical Informatics · doi:10.1055/s-0038-1645889 · Cited by 14
How Do Residents Spend Their Time in the Intensive Care Unit?
Cartmill, R. S., Roy, K. S. V., Carayon, P., et al. (2015) · The American Journal of the Medical Sciences · doi:10.1097/maj.0000000000000520 · Cited by 14
“This result highlights the need to understand the local organizational and sociotechnical context that can influence tasks performed by residents.(21) Alternatively, the authors did not find significant differences in tasks performed by residents in the PICUs of the 2 MCs.”
Self-citationHøyland, S. A., Holte, K. A., Islam, M. K., Øygaarden, O., Kjerstad, E., Høyland, S. A., Wærnes, H. R., Gürgen, M., Conde, K. B., Hovland, K. S., et al. (2022) · International Wound Journal · doi:10.1111/iwj.13986 · Cited by 13
Self-citationBuoro, S., Rin, G. D., Fanelli, A., et al. (2018) · Clinical Chemistry and Laboratory Medicine (CCLM) · doi:10.1515/cclm-2017-0972 · Cited by 14
A tale of 2 digital hospitals: A qualitative study of antimicrobial stewardship teams
Dort, B. A. V., Ritchie, A., Penm, J. H.-D., Gray, T. J., Ronnachit, A., & Baysari, M. T. (2024) · British Journal of Clinical Pharmacology · doi:10.1111/bcp.16001 · Cited by 14
Cochon, L. R., Lacson, R. C., Wang, A., Kapoor, N., Ip, I. K., Desai, S. P., Kachalia, A. B., Dennerlein, J. T., Benneyan, J. C., & Khorasani, R. (2018) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocy103 · Cited by 15
Slow adoption of automated infection prevention surveillance: Are human factors contributing?
Hebden, J. N. (2015) · American Journal of Infection Control · doi:10.1016/j.ajic.2015.02.007 · Cited by 14
“An examination of factors that may be contributing to the slow adoption by ICPs of automated surveillance technology can be viewed in the context of the Systems Engineering Initiative for Patient Safety described by Carayon et al.(15) The human factors field is concerned with the interaction between people, machines,…”
MethodQuality of uncomplicated malaria case management in Ghana among insured and uninsured patients
Fenny, A. P., Hansen, K. S., Enemark, U., et al. (2014) · International Journal for Equity in Health · doi:10.1186/s12939-014-0063-9 · Cited by 14
“Some suggest that there are other important factors such as patient characteristics and environmental factors that need to be incorporated for a more complete evaluation of quality care [31-33].”
BackgroundLearning from Aviation to Improve Safety in the Operating Room ‐ a Systematic Literature Review
Wauben, L. S. G. L., Lange, J. F., & Goossens, R. (2012) · Journal of Healthcare Engineering · doi:10.1260/2040-2295.3.3.373 · Cited by 14
“[39] show in their SEIPS model (Systems Engineering Initiative for Patient Safety) that the work system entails five components that are interrelated.”
MethodYanke, E., Moriarty, H., Carayon, P., & Safdar, N. (2018) · Journal of Patient Safety · doi:10.1097/pts.0000000000000500 · Cited by 18
“Systems Engineering Initiative for Patient Safety model.(9,10) J Patient Saf • Volume 17, Number 8, December 2021 The Invisible Staff”
BackgroundSelf-citationBergman, L., Chaboyer, W. P., Pettersson, M. E., & Ringdal, M. (2020) · BMJ Open · doi:10.1136/bmjopen-2020-038424 · Cited by 14
Information governance as a socio-technical process in the development of trustworthy healthcare AI
Rees, N., Holding, K., & Sujan, M. A. (2023) · Frontiers in Computer Science · doi:10.3389/fcomp.2023.1134818 · Cited by 17
“Similarly, ergonomics studies assess the influence of and the impact on wider system interactions, such as the interaction with people, their tasks, other tools and equipment being used, as well as the organizational processes and cultures (Carayon et al., 2006).”
BackgroundInitial development of the Systems Approach to Home Medication Management (SAHMM) model
Doucette, W., Vinel, S., & Pennathur, P. (2017) · Research in Social and Administrative Pharmacy · doi:10.1016/j.sapharm.2015.12.013 · Cited by 17
Evaluation of Ceiling Lifts in Health Care Settings
Alamgir, H., Li, O. W., Gorman, E., et al. (2009) · AAOHN Journal · doi:10.1177/216507990905700904 · Cited by 14
“Models evaluating patient and employee safety include similar input and analytical processes (Carayon et al., 2006; Karsh, Holden, Alper, & Or, 2006).”
BackgroundSystem Factors Influencing the Use of a Family-Centered Rounds Checklist
Kelly, M. M., Xie, A., Li, Y., Cartmill, R. S., COX, E. D., Brown, R., Wetterneck, T. B., & Carayon, P. (2019) · Pediatric Quality and Safety · doi:10.1097/pq9.0000000000000196 · Cited by 14
Self-citationMcKay, J., Pickup, L., Atkinson, S., et al. (2016) · Education for Primary Care · doi:10.1080/14739879.2016.1181533 · Cited by 13
“Work organisation must be considered as part of any implementation of change to reduce risk factors at work [5, 13, 23].”
BackgroundSearching for management approaches to reduce HAI transmission (SMART): a study protocol
McAlearney, A. S., Hefner, J. L., Sieck, C. J., et al. (2017) · Implementation Science · doi:10.1186/s13012-017-0610-z · Cited by 13
Williams, R., Aldakhil, R., BLANDFORD, A. E., & Jani, Y. H. (2021) · BMJ Open · doi:10.1136/bmjopen-2020-044419 · Cited by 16
“25 This literature review identifies factors which enable and limit the use of BCMA, during the implementation phase and beyond, by using a human factors lens to capture primary research from both users and imple-menters of the technology.”
BackgroundJarrar, M., Al‐Bsheish, M., Albaker, W. I., Alsaad, I., Alkhalifa, E. A., Alnufaili, S., Almajed, N., Alhawaj, R. Z., Al-Hariri, M. T., Alsunni, A. A., et al. (2023) · Risk Management and Healthcare Policy · doi:10.2147/rmhp.s392523 · Cited by 19
“The theoretical framework of this study was built using social exchange theory(30) and incorporating the model of Systems Engineering Initiative for Patient Safety (SEIPS).(31) The social exchange theory concentrates on developing healthy workplace relationships between staff and their managers for the mutual benefit…”
MethodFabius, C. D., Wec, A., Saylor, M. A., et al. (2023) · Geriatric Nursing · doi:10.1016/j.gerinurse.2023.09.001 · Cited by 13
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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