The SEIPS Model is based on the Balance Theory of Job Design
(Smith and Carayon, 1989, 1995; Carayon and Smith, 2000)

The Systems Engineering Initiative for Patient Safety (SEIPS)

The Systems Engineering Initiative for Patient Safety (SEIPS), housed within CQPI, is a multidisciplinary initiative applying systems engineering, human factors engineering, and quality engineering approaches. This research empirically examines systems design, quality management, job design, and technology implementations that affect safety-related patient and organizational and/or staff outcomes (Carayon et al., 2006; Karsh, et al, 2006). SEIPS was one of 18 patient safety developmental centers originally funded by the Agency for Healthcare Research and Quality (AHRQ), the only such center located in a college of engineering.

SEIPS draws on its own members’ expertise, scientific literature, and research findings to develop educational programs on patient safety issues. The educational programs are aimed internally for use in developing a coherent research team and externally for medical consumers, medical providers, and the research community. Ties to local medical delivery systems have been formalized. A core planning team, research affiliates, community affiliates, and student affiliates are part of the SEIPS structure. Oversight and direction is provided to SEIPS by the core planning team comprised of representatives from the UW School of Medicine and Population Health (SMPH) – Maureen Smith, MD, PhD, MPH who functions as the liaison between SEIPS and ICTR-CAP (see below for the description), Tosha Wetterneck, MD, MSCaprice Greenberg, MD, MPHAmye Tevaarwerk, MDSharon Weber, MD, and Carla Pugh, MD, PhD; School of Nursing - Linsey Steege, PhDRoger L. Brown, PhD, and Barbara King, PhD, RN; School of Pharmacy – Michelle Chui, PharmD, PhD; College of Engineering – Pascale Carayon, PhDDouglas Wiegmann, PhD, Carla Alvarado, PhD, CICAnn Schoofs Hundt, PhDMary Sesto, PhDJohn Lee, PhDJingshan Li, PhD, and Vicki Bier, PhD, who, as chair of the department, functions as the liaison between SEIPS and Industrial and Systems Engineering faculty.

SEIPS hosts speakers and Brown Bag seminars to lead discussion on issues relevant to health care and patient safety. Most seminars are recorded and accessible through the Innovations in Medical Education website.  


Current Projects

Past Projects

    Kelly, M.M., Hoonakker, P.L.T. & Dean, S. (2016). Using a patient portal to engage families in pediatric hospital care. JAMIA, 1. doi:10.1093/jamia/ocw070.

    Kelly, M.M., Hoonakker, P.L.T., Bunton, J., & Dean, S. (2016). Using a Patient Portal to Engage Parents in Hospital Care. Presented at the Pediatric Academic Societies (PAS) Meeting, Baltimore, MD, April 30-May 3, 2016.

    Kelly, M.M., Hoonakker, P.L.T., Rankin, R. & Dean, S. (2016). A Portal for Families of Hospitalized Children: Healthcare Team Perspectives. Paper presented at the Pediatric Academic Societies (PAS) Meeting, Baltimore, MD, April 30-May 3, 2016.

    Benjamin, J.M., Cox, E.D., Trapskin, P.J., Rajamanickam, V.P., Jorgenson, R.C., Weber, H.L., Pearson, R.E., Carayon, P. & Lubcke, N.L. (2015). Family-Initiated Dialogue About Medications During Family-Centered Rounds. Pediatrics, 135(1), 94-101.

    Carayon, P., Hundt, A.S., Hoonakker, P.L.T., Kianfar, S., Alyousef, B., Salek, D., Cartmill, R., Walker, J.W., Tomcavage, J. (2015). Perceived impact of care managers’ work on patient and clinician outcomes. European Journal for Person Centered Healthcare, 3(2), 158-167.

    Carayon, P., Wetterneck, T.B., Alyousef, B., Brown, R.L., Cartmill, R.S., McGuire, K., Hoonakker, P.L.T., Slagle, J., Schultz van Roy, K., Walker, J.M., Weinger, M.B., Xie, A., & Wood, K.E. (2015). Impact of electronic health records technology on the work and workflow of physicians in the intensive care units. International Journal of Medical Informatics (IJMI), 84 (8), 578-594. http://dx.doi.org/10.1016/j.ijmedinf.2015.04.002

    Holden, R.J., McDougald Scott, A., Hoonakker, P., Hundt, A.S., & Carayon, P. (2015). Data collection challenges in community settings: Insights from two field studies of patients with chronic disease. Quality of Life Research, 24, 1043-1055 PMCID: PMC4342308

    Xie, A., Carayon, P., Cox, E.D., Cartmill, R., Li, Y., Wetterneck, T.B., & Kelly, M.M. (2015). Application of participatory ergonomics to the redesign of the family-centred rounds process. Ergonomics, 58(10): 1726-1744.

    Xie, A., Carayon, P., Cartmill, R., Li, Y., Cox, E.D., Plotkin, J.A., & Kelly, M.M. (2015). Multi-stakeholder collaboration in the redesign of family-centered rounds process Applied Ergonomics, 46, 115-123.

    Hoonakker, P.L.T., Lu, Y, Li, Y, Carayon, P. (2015). Nurses’ workload in different medical settings. Proceedings of the Care4 Conference, Antwerp, Belgium, Feb 4-6, 2015, p. 20.

    Carayon, P., Grepo, L., Patterson, B., Li, Y., Hundt, A.S., Cartmill, R.S., Hoonakker, P.L.T., Wood, K. (2015). Role Network Analysis of Venous Thromboembolism (VTE) Diagnosis in the Emergency Department. Paper presented at the ISCOME conference, Montecatini Terme, Italy, June 15-16, 2015.

    Hoonakker, P.L.T., Carayon, P., Cartmill, R.S., Hundt, A.S., Grepo, L., Li, Y., Stamm, J., Wood, K. (2015). Communication Strategies for Venous Thromboembolism Prophylaxis. Paper presented at the ISCOME conference, Montecatini Terme, Italy, June 15-16, 2015.

    Carayon, P., Hoonakker, P. L., Cartmill, R., Hassol, A. (2015). Using Health Information Technology (IT) in Practice Redesign: Impact of Health IT on Workflow. Patient-Reported Health Information Technology and Workflow. (Prepared by Abt Associates under Contract No. 290-2010-00031I). AHRQ Publication No. 15-0043-EF. Rockville, MD: Agency for Healthcare Research and Quality. May 2015. http://www.ahrq.gov/news/healthit.html

    Kelly, M.M., Cox, E.D., Xie, A., Li, Y., Cartmill, R., & Carayon, P. (2014). Evaluating the implementation of family-centered rounding checklist. Paper presented at the 2014 Annual Pediatric Academic Society Meeting, Vancouver BC, Canada.

    Carayon, P., Li, L., Kelly, M.M., DuBenske, L.L., Xie, A., McCabe, B., Orne, J., & Cox, E.D. (2014). Stimulated recall methodology for assessing work system barriers and facilitators in family-centered rounds in a pediatric hospital. Applied Ergonomics, 45 (6), 1540-1546. PMCID: PMC4119819

    Pecenac, K., Hoonakker, P., Brown, R., & Carayon, P. (2014). Virtual intensive care unit nurses' trust and satisfaction of monitored bedside intensive care unit nurses. Paper presented at the Academy Health Conference, San Diego, CA.

    Kianfar, S., Li, Y., Carayon, P., Hundt, A.S., & Hoonakker, P. (2014). Understanding care coordination for chronically ill patients? Paper presented at the Human Factors and Ergonomics (HFES) Society's 58th Annual Meeting, Chicago, IL.

    Hundt, A.S., Carayon, P., Alyousef, B., Cartmill, R.S., Hoonakker, P., Kianfar, S., Tomcavage, J., Salek, D., Petrucci, J., & Walker, J. (2014). Community ergonomics applied to the implementation of a region-wise care coordination program. Proceedings of the 11th International Symposium on Human Factors in Organizational Design and Management (ODAM) Copenhagen, Denmark. pp. 475-480.

    Hoonakker, P., Carayon, P., Hundt, A.S., Cartmill, R.S., & Nathan-Roberts, D. (2014). Challenges of doing research that involves patients. Proceedings of the 11th International Symposium on Human Factors in Organizational Design and Management (ODAM) Conference, Copenhagen, Denmark. pp. 19-24.

    Li, Y., Carayon, P, Hundt, A.S., Kianfar, S., Hoonakker, P., Salek, D., & Tomcavage, J. (2014). Levels of strategies used by care managers to deal with health IT-related barriers. Proceedings of the 11th International Symposium on Human Factors in Organizational Design and Management (ODAM) Conference, Copenhagen, Denmark. pp 469-474.

    Xie, A., Kelly, M.M., Cox, E.D., Cartmill, R.S., Li, Y., & Carayon, P. (2014). A participatory ergonomics approach to family-centered rounds process redesign. Paper presented at the 2014 Symposium on Human Factors and Ergonomics in Health Care: Leading the Way, Chicago, IL.

    Cox, E.D., Carayon, P., Hansen, K.W., Rajamanickam, V.P., Brown, R.L., Rathouz, P.J., Dubenske L.L., Kelly, M.M. & Buel, L.A. (2013). Parent perceptions of children's hospital safety climate. BMJ Quality & Safety, 22(8), 664-671.

    Waterson, P., Hoonakker, P.L.T., Carayon, P. (2013). Special issue on human factors and the implementation of health information technology (HIT): Comparing approaches across nations. International Journal of Medical Informatics, 27, (5) 277-280. PMID: 23375708

    Hoonakker, P., Carayon, P., Cartmill, R.S., Kern, L., Hundt, A.S., Salek, D., Petrucci, J., Tomcavage, J., Topper, J., Hassol, A., & Walker, J. (2013). Inside the black box: What do inpatient case managers do? Paper presented at the Human Factors and Ergonomics Society (HFES) Symposium on Health Care, Baltimore, MD.

    Carayon, P., Wetterneck, T.B., Cartmill, R.S., Blosky, M.A., Brown, R.L., Kim, R., Kukreja, S., Johson, M.A., Paris, B., Wood, K.E., & Walker, J. (2013). Characterising the complexity of medication safety using a human factors approach: An observational study in two intensive care units. BMJ Quality & Safety, 23 (1), 56-65. PMCID: PMC3938094

    Kelly, M.M., Xie, A., Carayon, P., DuBenske, L.L., Ehlenbach, M.L., & Cox, E.D. (2013). Strategies for improving family engagement during family-centered rounds. Journal of Hospital Medicine, 8 (4), 201-207. PMCID: PMC3955089

    Hundt, A.S., Adams, J.A., Schmid, J.A., Musser, L.M., Walker, J., Wetterneck, T.B., Douglas, S.V., Paris, B.L., & Carayon, P. (2013). Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit. International Journal of Medical Informatics, 82 (1), 25-38. PMCID: PMC3430828

    Hoonakker, P., Carayon, P., McGuire, K., Khunlertkit, A., Wiegmann, D., Alyousef, B. Xie, A. & Wood, K. (2013). Motivation and job satisfaction of Tele-ICU Nurses. Journal of Critical Care, 28 (3), 315.e13–315.e21. PMID: 23159143

    Hoonakker, P., Carayon, P., Brown, R.L., Cartmill, R.S., Wetterneck, T.B., & Walker, J. (2013). Changes in end-user satisfaction with computerized provider order entry over time among nurses and providers in intensive care units. Journal of the American Medical Informatics Association, 20 (2), 252-259. PMCID: PMC3638190

    Rivera-Rodriguez, A.J. (2013). A socio-technical systems approach to studying interruptions: Understanding the interrupter's perspective. Applied Ergonomics, 45 (3), 747-756. PMID: 24103213

    Karsh, B-T., Waterson, P., & Holden, R.J. (2013). Crossing levels in systems ergonomics: A framework to support 'mesoergonomics' inquiry. Applied Ergonomics, 45 (1), 45-54. PMID: 23706573

    Holden, R.J., Carayon, P., Gurses, A.P., Hoonakker, P., Hundt, A.S., Ozok, A.A., & Rivera-Rodriguez, A.J. (2013). SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics, 56 (11), 1669-1686. PMCID: PMC3835697

    Douglas, S., Cartmill, R.S., Brown, R., Hoonakker, P., Slagle, J., Van Roy, K., Walker, J.M., Weinger, M.B., Wetterneck, T., & Carayon, P. (2013). The work of adult and pediatric intensive care unit nurses. Nursing Research, 62 (1), 50-58. PMID: 23222843

    Hoonakker, P., Carayon, P., Walker, J., Brown, R.L., & Cartmill, R.S. (2013). The effects of Computerized Provider Order Entry implementation on communication in Intensive Care Units. International Journal of Medical Informatics, 82 (5), 107-117. PMCID: PMC3624062

    Khunlertkit, A. & Carayon, P. (2013). Contributions of tele–intensive care unit (Tele-ICU) technology to quality of care and patient safety. Journal of Critical Care, 28 (3), 315.e1-315.e12. PMID: 23159139

    Alyousef, B. (2013). Human factors challenges of patient-related information management for care coordination. PhD Dissertation, (Order No. 3592941), University of Wisconsin - Madison.

    Xie, A. (2013). A participatory ergonomics approach to family-centered rounds process redesign: The case of family-centered rounds in a pediatric hospital. PhD Dissertation, (Order No. 3594091), University of Wisconsin - Madison.

    Kianfar, S., Carayon, P., Hundt, A.S., Hoonakker, P., Alyousef, B., Tomcavage, J., Salek, D., Petrucci, J., Hassol, A., Walker, J. (2013). Care providers’ perception of care coordination team members. Poster presented at the Human Factors and Ergonomics Society (HFES) Symposium on Health Care, Baltimore, MD.

    Hoonakker, P., Alyousef, B., Kianfar, S., Carayon, P. Cartmill, R.S., Hassol, Hundt, A.S., Ladd, I., Yule, C., Chaundy, K., Honicker, M., Younkin, J., & Walker, J. (2013). Assessment of use, usability, and clinicians’ satisfaction with the Keystone Health Information Exchange. Poster presented at the Human Factors and Ergonomics Society (HFES) Symposium on Health Care, Baltimore, MD.

    Carayon, P. (2013). Reengineering Health Care Through a Human Factors Systems Approach. Paper presented at the 2013 Symposium on Human Factors and Ergonomics in Health Care, Baltimore, MD.

    Li, Y., Carayon, P., Xie, A., Kelly, M.M., Cartmill, R.S., Wetterneck, T.B., & Cox, E.D. (2013). Work system challenges to implementing a family-centered rounds checklist. Poster presented at the 2013 International Symposium on Human Factors and Ergonomics in Healthcare: Advancing the Cause, Baltimore, MD.

    Carayon, P., Kianfar, S., Hundt, A.S., Tomcavage, J., Salek, D., Petrucci, J., Hoonakker, P., Alyousef, B., Walker, J. (2013). Health IT-related obstacles and facilitators in coordinating care for patients with chronic illness: A longitudinal study. Paper presented at the 11th International Conference on Naturalistic Decision Making, Marseille, France

    Alyousef, B., Carayon, P., Hoonakker, P., Hundt, A.S., Cartmill, R.S., Tomcavage, J., Hassol, A., Chaundy, K., Younkin, J., & Walker, J. (2012). Care managers' challenges in using multiple health IT applications. Proceedings of the Human Factors and Ergonomics Society (HFES) 56th Annual Meeting, Boston, MA. pp. 1748-1752.

    Xie, A., Carayon, P., Kelly, M.M., Li, Y., Cartmill, R.S., DuBenske, L. L., Brown, R.L., & Cox, E. D. (2012). Managing different perspectives in the redesign of family-centered rounds in a pediatric hospital. Proceedings of the Human Factors and Ergonomics Society (HFES) Annual Meeting, 56 (1), 1733-1737.

    Cartmill, R.S., Walker, J.M., Blosky, M.A., Brown, R.L., Djurkovic, S., Dunham, D.B., Gardill, D., Haupt, M.T., Parry, D., Wetterneck, T.B., Wood, K.E., & Carayon, P. (2012). Impact of electronic order management on the timeliness of antibiotic administration in critical care patients. International Journal of Medical Informatics, 81 (11), 782-791. PMID: 22947701

    Carayon, P., Alyousef, B., Hoonakker, P., Hundt, A.S., Cartmill, R.S., Tomcavage, J., Hassol, A., Chaundy, K., Larson, S., Younkin, J. & Walker J. (2012). Challenges to care coordination posed by the use of multiple health IT applications. Work, 41 (2), 4468-4473. PMID: 22317409

    Hoonakker, P., Khunlertkit, A., Tattersall, M., & Keevil, J. (2012). Computer decision support tools in primary care. Work, 41 (2), 4474-4478. PMCID: PMC3642990

    Carayon, P., Cartmill, R.S., Hoonakker, P., Hundt, A.S., Karsh, B.-T., Krueger, D., et al. (2012). Human factor analysis of workflow in health information technology implementation. In Carayon (Ed.). Handbook of Human Factors and Ergonomics in Patient Safety, (2 ed., pp. 507-521). CRC Press: Boca Raton, FL.

    Carayon, P. (2012). Handbook of Human Factors in Health Care and Patient Safety. (2nd ed.) CRC Press: Boca Raton, FL.

    Bisantz, A.M., Carayon, P., Miller, A., Khunlertkit, A., & Arbaje, A. (2012). Using human factors and systems engineering to improve care coordination. Paper presented at the Human Factors and Ergonomics Society (HFES) 56th Annual Meeting, Boston, MA.

    Hundt, A.S., Carayon, P., Hoonakker, P., Cartmill, R.S., Den Herder, R., Topper, J., Younkin, J., & Walker, J. (2012). Organizational learning in a large-scale complex health IT project. Proceedings of the Human Factors and Ergonomics Society (HFES) Annual Meeting, Boston, MA. pp. 1288-1292.

    Hassol, A., Woo, M., Ball, S., Izrael, D., Carayon, P., Hoonakker, P., Ladd, I., Yule, C, Younkin, J., Chaundy, K., Larson, S., Walker, J.M. (2012). Chronic Care Patients’ Attitudes Regarding Electronic Health Information Exchange. Paper presented at the American Medical Informatics Association Meeting.

    Carayon, P., Hoonakker, P., Tomcavage, J., Salek, D., Hassol, A., Cartmill, R.S., Hundt, A.S., Ladd, I., Yule, C., Younkin, J., Chaundy, K., & Walker J. (2012). Case managers’ acceptance of health IT applications. Poster presented at the American Medical Informatics Association Meeting.

    Hoonakker, P., Carayon, P., Gurses, A., Brown, R., Khunlertkit, A., McGuire, K., & Walker, J.M. (2011). Measuring workload of ICU nurses with a questionnaire survey: The NASA Task Load Index (TLX). IIE Transactions on Healthcare Systems Engineering, 1 (2), 131-143. PMCID: PMC3388621

    Wetterneck, T.B., Lapin, J., Krueger, D., Homan, G., Beasley, J., & Karsh, B-T. (2011). Development of a primary care physician task list to evaluate clinic visit workflow. British Medical Journal: Quality & Safety, 21 (1), 47-53. PMCID: PMC3568931

    Wetterneck, T.B., Lapin, J., Beasley, J., Smith, P., & Karsh, B.-T. (2011). Please, can I have one visit where I have all the information I need? Paper presented at the 2011 Wisconsin Health Improvement and Research Partnership Forum, Madison, WI.

    Wetterneck, T.B. & Holman, G.T. (2011). Use of tandem observations in ambulatory primary care to evaluate physician. Paper presented at the 3rd International Conference Healthcare Systems Ergonomics and Patient Safety Conference, Oviedo, Spain.

    Wetterneck, T.B. & Holman, G.T. (2011). Failures and recovery. Paper presented at the Wisconsin Health Improvement and Research Partnerships Forum, Madison, WI.

    Wetterneck, T.B. (2011). Hazards & information chaos in the primary care of the elderly. Department of Family Medicine Statewide Research Forum.

    Wetterneck T.B. (2011). Error recovery in health care. In P. Carayon (Ed.). Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, (2 ed., pp. 449-461). CRC Press: Boca Raton, FL.

    Lapin, J., Krueger, D., Wetterneck, T.B., Holman, G.T., Beasley, J., & Karsh, B.-T. (2011). The myth of primary care workflow. Paper presented at the Primary Care Work-life to Wellness: Engineering Quality, Safety, and Satisfaction, Wisconsin Dells, WI.

    Hoonakker, P., Wetterneck, T., Carayon, P., Cartmill, R.S., & Walker, J. (2011). Drug alerts override from a human factors perspective. Proceedings of the Healthcare Ergonomics Systems and Patient Safety (HEPS) Conference, Oviedo, Spain. pp. 367-371.

    Beasley, J., Wetterneck, T.B., Temte, J., Lapin, J.A., Smith, P.A., Rivera-Rodriguez, A.J., & Karsh, B.-T. (2011). Information chaos in primary care: Implications for physician performance and patient safety. The Journal of the American Board of Family Medicine 24 (6), 745-751. PMCID: PMC3286113

    Hoonakker, P., Cartmill, R.S., Carayon, P., & Walker, J. (2011). Development and psychometric qualities of the SEIPS survey to evaluate CPOE/EHR implementation in ICUs. International Journal of Healthcare Information Systems and Informatics, 6 (1), 51-69. PMCID: PMC3070305

    Carayon, P., Cartmill, R.S., Blosky, M.A., Brown, R., Hackenberg, M., Hoonakker, P., Hundt, A.S., Norfolk, E., Wetterneck, T.B. & Walker, J. (2011). ICU nurses’acceptance of electronic health records. Journal of the American Medical Informatics Association, 18 (6), 812-819. PMCID: PMC3197984

    Wetterneck, T., Walker, J., Blosky, M.A., Cartmill, R.S., Hoonakker, P., Johnson, M.A., Norfolk, E., & Carayon, P. (2011). Factors contributing to an increase in duplicate medication order errors after CPOE implementation. Journal of the American Medical Informatics Association, 18 (6), 774-782. PMCID: PMC3198002

    Hoonakker, P., McGuire, K., & Carayon, P. (2011). Sociotechnical Issues of Tele-ICU Technology. In D.M. Haftor & A. Mirijamdotter (Eds.). Information and Communication Technologies, Society and Human Beings: Theory and Framework, (pp. 225-240). IGI Global: Hershey, PA.

    Hoonakker, P. (2011). Human Factors in Telemedicine. In P. Carayon (Ed.). Handbook of Human Factors and Ergonomics in Patient Safety, (2 ed., pp. 293-304). CRC Press: Boca Raton, FL.

    Hoonakker, P., Carayon, P., Khunlertkit, A., McGuire, K., & Wiegmann, D. (2011). Case study research: An example from the tele-ICU. Paper presented at the ODAM Conference 2011, Grahamstown, South Africa.

    Carayon, P., Cartmill, R.S., Blosky, M.A., Brown, R., Hackenberg, M., Hoonakker, P., Hundt, A.S., Norfolk, E., Wetterneck, T.B. & Walker, J. (2011). EHR acceptance by ICU physicians and nurses. Proceedings of the Healthcare Ergonomics Systems and Patient Safety (HEPS) Conference, Oviedo, Spain.

    Hoonakker, P., Khunlertkit, A., McGuire, K., Wiegmann, D., & Carayon, P. (2011). A day in life of tele-Intensive Care Unit nurse. Proceedings of the Healthcare Ergonomics Systems and Patient Safety (HEPS), Oviedo, Spain.

    Khunlertkit, A. (2011). The role of the tele-ICU technology in quality of care and patient safety of intensive care unit. PhD Dissertation, University of Wisconsin - Madison.

    Carayon, P., Hoonakker, P., Wiegmann, D., Khunlertkit, A., McGuire, K., Brown, R., et al. (2011). Building and maintaining simultaneous dynamic relationships in a virtual organization: The case of tele-intensive care units. National Science Foundation, Arlington, VA.

    McGuire, K., Carayon, P., Hoonakker, P., Khunlertkit, A., & Wiegmann, D. (2010). Communication in the tele-ICU. Paper presented at the Systems Engineering Initiative for Patient Safety (SEIPS) Short Course, Madison, WI.

    Lapin, J., Krueger, D., Wetterneck, T.B., Holman, G.T., Beasley, J., & Karsh, B.-T. (2010). Workflow Schmerkflow. Paper presented at the Wisconsin Primary Care Research and Quality Improvement Forum, Middleton, WI.

    Lapin, J., Krueger, D., Wetterneck, T.B., Holman, G.T., Beasley, J., & Karsh, B.-T. (2010). Quality improvement from a human factors perspective. Paper presented at the Harvard Medical School: Update in Medicine Conference, Boston, MA.

    Lapin, J., Beasley, J., Smith, P., Hagenauer, M.E., & Karsh, B.-T. (2010). Hazards in the primary care of elderly patients: A qualitative analysis of physician hazard reports. Paper presented at the Family Medicine 40th Anniversary Celebration, Madison, WI.

    Wiegmann, D., Eggman, A., Elbardissi, A., Parker, S.H., & Sundt, T.M. (2010). Improving cardiac surgical care: A work systems approach. Applied Ergonomics, 41 (5), 701-712. PMCID: PMC2879339

    Karsh, B.-T. & Brown, R. (2010). Macroergonomics and patient safety: The impact of levels on theory, measurement, analysis and intervention in patient safety research. Applied Ergonomics, 41 (5), 674-681. PMID: 20153456

    Carayon, P. (2010). Human factors in patient safety as an innovation. Applied Ergonomics, 41 (5), 657-665. PMCID: PMC2873106

    Hoonakker, P., Carayon, P. & Walker, J. (2010). Measurement of CPOE end-user satisfaction among ICU physicians and nurses. Applied Clinical Informatics, 1 (3), 268-285. PMCID: PMC3059318

    Carayon, P., Hundt, A.S., & Wetterneck, T.B. (2010). Nurses' acceptance of smart IV pump technology. International Journal of Medical Informatics, 79 (6), 401-411. PMCID: PMC2862878

    Faye, H., Rivera-Rodriguez, A.J., Karsh, B.-T., Hundt, A.S., Baker, C., & Carayon, P. (2010). Involving ICU nurses in a proactive risk assessment of the medication management process. Joint Commission Journal of Quality and Safety, 36 (8), 376-384. PMCID: PMC3039839

    Wetterneck, T.B., Cartmill, R.S., Walker, J.M., Carayon, P. (2010). Duplicate medication orders after CPOE implementation. Journal of Hospital Medicine, 5 (3), 81.

    McGuire, K. (2010). Interpersonal trust from the viewpoint of tele-ICU nurses. Paper presented at the Annual National Research Services Award Trainees Conference, Boston, MA.

    Hoonakker, P., Carayon, P., Wood, K., & Walker, J. (2010). Implementation of healthcare technology and workload of nurses in the intensive care units. Poster presented at the ICOH WOPS Conference, Amsterdam, The Netherlands.

    Carayon, P. & Karsh, B.-T. (2010). Workflow toolkit and lessons in user centered design. Paper presented at the 2010 AHRQ Conference, Washington D.C.

    Hoonakker, P., Cartmill, R.S., Carayon, P., & Walker, J. (2010). Development of the survey to evaluate CPOE/EHR implementation in ICUs. Technical Report, Center for Quality and Productivity Improvement (CQPI), Madison, WI.

    Carayon, P., Karsh, B-T., Cartmill, R.S., et al. (2010). Incorporating Health Information Technology Into Workflow Redesign. Summary Report, AHRQ Publication: Rockville, MD.

    Wetterneck, T.B. & Holman, G.T. (2009). Medication information management and error recovery in primary care clinics. Paper presented at the Wisconsin Primary Care Research and Quality Improvement Forum, Madison, WI.

    Wetterneck, T.B., Hundt, A.S., & Carayon, P. (2009). FMEA team performance in health care: A qualitative analysis of team member perceptions. Journal of Patient Safety, 5 (2), 102-108. PMID: 19920449

    Carayon, P., Smith,P., Hundt, A.S., Kuruchittham, V. & Li, Q. (2009). Implementation of an electronic health records system in a small clinic: The viewpoint of clinic staff. Behaviour and Information Technology, 28 (1), 5-20.

    Carayon, P. (2009). The balance theory and the work system model... Twenty years later. International Journal of Human- Computer Interaction, 25 (5), 313-327.

    Faye, H., Rivera, A. J., Karsh, B.-T., Murray, M. E., Baker, C., & Carayon, P. (2009). Nurses' perceptions of medication management. Poster presented at the 21st Annual Conference for Teachers of Nursing Practice, Madison, WI.

    Carayon, P. & Wood, K.E. (2009). Patient safety: The role of human factors and systems engineering. In Rouse & Cortese (Eds.). Engineering the System of Healthcare Delivery, (pp. 23-46). IOS Press: Amsterdam, The Netherlands.

    Wetterneck, T., Paris, B., Blosky, M.A., Cartmill, R.S., Walker, J., & Carayon, P. (2008). Error recovery in the ICU medication use process. Paper presented at the Healthcare Ergonomics Systems and Patient Safety (HEPS) 2008 Conference, Strasbourg, France.

    Koppel, R., Wetterneck, T., Telles, J.L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15 (4), 408-423. PMCID: PMC2442264

    Hoonakker, P., Carayon, P., Douglas, S., Schulz, K., Walker, J.M., & Wetterneck, T.B. (2008). Communication in intensive care units. Paper presented at the ODAM 2008 Conference, Guaruja, Brazil.

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Rough, S., & Schroeder, M. (2008). Continuous technology implementation in health care: The case of advanced IV infusion pump technology. In Zink & Klaus (Eds.). Corporate Sustainability as a Challenge for Comprehensive Management. (pp. 139-151). Springer Press: Dordecht, The Netherlands.

    Faye, H., Carayon, P., Karsh, B.-T., Rivera, A. J., Murray, M. E., Scanlon, M., et al. (2008). ICU nurse medication management: Decision-making in a complex environment. Paper presented at the Healthcare Ergonomics Systems and Patient Safety (HEPS) Conference, Strasbourg, France.

    Hoonakker, P., Carayon, P., Douglas, S., Schulz, K., Walker, J., & Wetterneck, T.B. (2008). Communication in the ICU and then relation with quality of care and patient safety from a nurse perspective. Paper presented at the Human Factors and Ergonomics Society (HFES) 54th Conference, San Franscisco, CA.

    Beard, V.A. & Cartmill, R.S. (2008). Gender and participation in community development in Indonesia. In Matthew & Goldsworthy (Eds.). Women and Human Security: Challenges of Conflict and Global Change.

    Beard, V.A., Pradhan, M., Vao, R., Cartmill, R.S., & Rivayani. (2008). Decentralization, community-driven development and elite capture: Microcredit and community board participation in Indonesia. Paper presented at the Association of Collegiate Schools of Planning Conference, Chicago, IL.

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Ozkaynak, M., DeSilvey, J., Ludwig, B., Ram, P., & Rough, S.S. (2007). Evaluation of nurse interaction with Bar Code Medication Administration (BCMA) technology in the work environment. Journal of Patient Safety, 3 (1), 34-42.

    Schultz, K., Carayon, P., Hundt, A.S., & Springman, S.R. (2007). Care transitions in the outpatient surgery process: Facilitators and obstacles to information flow and their consequences. Cognition, Technology & Work, 9 (4), 219-231.

    Holden, R.J. & Karsh, B.-T. (2007). A review of medical error reporting system design considerations and a proposed cross-level system research framework. Human Factors, 49 (2), 257-276.

    Beard, V.A. & Cartmill, R.S. (2007). Gender, collective action and participatory development in Indonesia. International Development Planning Review, 29 (2), 185-213.

    Carayon, P., Hundt, A.S., Alvarado, C., Springman, S.R., & Ayoub, P. (2006). Patient safety in outpatient surgery: The viewpoint of the healthcare providers. Ergonomics, 49 (5-6), 470-485. PMID: 16717005

    Carayon, P. (2006). Human factors of complex sociotechnical systems. Applied Ergonomics, 37 (4), 525-535. PMID: 16756937

    Schroeder, M.E., Wolman, R.L., Wetterneck, T.B., & Carayon, P. (2006). Tubing misload allows free flow even with smart intravenous infusion pump. Anesthesiology, 105 (2), 434-435. PMID: 16871089

    Wetterneck, T.B., Skibinski, K., Roberts, T.L., Kleppin, S.M., Schroeder, M.E., Enloe, M., Rough, S.S., Hundt, A.S., & Carayon, P. (2006). Using failure mode and effects analysis to plan implementation of smart IV pump technology. American Journal of Health-System Pharmacy, 63 (16), 1528-1538. PMID: 16896081

    Carayon, P., Hundt, A.S., Karsh, B-T., Gurses, A.P., Alvarado, C.J., Smith, M., & Brennan, P.F. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, i50-i58. PMCID: PMC2464868

    Li, Q., Douglas, S., Hundt, A.S., & Carayon, P. (2006). A heuristic evaluation of a computerized provider order entry (CPOE) technology. Proceedings of the IEA 2006 Congress, Elsevier Ltd.: London.

    Hundt, A.S., Carayon, P., & Wetterneck, T.B. (2006). HRO characteristics as demonstrated through implementation of a smart IV pump. In Pikaar, Koningsveld, & Seffels (Eds.). Proceedings of the IEA 2006 Congress, Maastricht, The Netherlands, Elsevier Ltd.: London.

    Wetterneck, T.B., Carayon, P., Hundt, A.S., & Kraus, S. (2006). Nurses' perception of smart IV pump technology characteristics and quality of working life. Paper presented at the IEA 2006 Congress, Maastricht, The Netherlands.

    Gurses, A.P. & Carayon, P. (2005). Identifying performance obstacles among intensive care nurses. Proceedings of the Human Factors and Ergonomics Society (HFES) 49th Annual Meeting, Santa Monica, CA. pp. 1019-1023.

    Hundt, A.S., Carayon, P., Springman, S.R., Smith, M., Florek, K., Sheth, R. & Dorshort, M. (2005). Outpatient surgery and patient safety – The patient's voice. In Henriksen, Battles, Marks, & Lewin (Eds.). Advances in Patient Safety: From Research to Implementation, AHRQ Publication. PMID: 21250022

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Ozkaynak, M., Ram, P., DeSilvey, J., Hicks, B., Roberts, T., Enloe, M., Sheth, R., & Sobande, S. (2005). Observing nurse interaction with infusion pump technologies. In Henrikson, Battles, Marks, & Lewin (Eds.). Advances in Patient Safety: From Research to Implementation. AHRQ Publication. PMID: 21249836

    Carayon, P., Alvarado, C. J., Hundt, A.S., Springman, S., Borgsdorf, A., & Hoonakker, P. (2005). An employee questionnaire for assessing patient safety in outpatient surgery. In Henrikson, Battles, Marks, & Lewin (Eds.). Advances in Patient Safety: From Research to Implementation, AHRQ Publication. PMID: 21250041

    Carayon, P., Gurses, A., Hundt, A.S., Ayoub, P., & Alvarado, C.J. (2005). Performance obstacles and facilitators of healthcare providers. In Korunka & Hoffman, (Eds.). Organization Psychology and Health Care, (vol. 4. Peiro and Schaufeli), Hampp Publishers: Munich.

    Schultz, K., Carayon, P., & Hundt, A.S. (2005). Patient care process and information flow in outpatient surgery. Proceedings of the Human Factors and Ergonomics Society (HFES) 49th Annual Meeting, Orlando, FL.

    Wetterneck, T.B., Carayon, P., Sobande, F., & Hundt, A.S. (2005). Technology characteristics predicting end user acceptance of SMArT intravenous infusion pumps. Proceedings of the Human Factors and Ergonomics Society (HFES) 49th Annual Meeting, Orlando, FL.

    Carayon, P., Wetterneck, T. B., Hundt, A. S., Enloe, M., Love, T., Rough, S., & Schroeder, M. (2005). Continuous technology implementation in health care: The case of advanced IV infusion pump technology. Paper presented at the 11th International Conference on Human-Computer Interaction, Las Vegas, NV.

    Wetterneck, T. B., Brown, R. L., Carayon, P., Kleppin, S., Hundt, A.S. & Ozkaynak, M. (2005). End-user response to intravenous infusion pump medication dosing alerts: An analysis of user-interface events. Paper presented at the Healthcare Systems Ergonomics and Patients Safety (HEPS) Conference, Florence, Italy.

    Hundt, A. S., Carayon, P., Wetterneck, T. B., Love, T., Haack, B., Schroeder, M. & Enloe, M. (2005). Evaluating design changes of a smart IV pump. In Tartaglia, Bagnara, Bellandi, & Albolino, (Eds.). Proceedings of the International Healthcare Systems, Ergonomics, and Patient Safety (HEPS) Conference, Florence, Italy. Taylor & Francis: London.

    Carayon, P., Wetterneck, T.B., Hundt, A.S., & Schroeder, M. (2004). Human factors in the design and implementation of patient safety technologies. Proceedings of the 15th ESCTAIC Annual Meeting, Toulouse, France.

    Carayon, P., Schultz, K., & Hundt, A.S. (2004). Righting wrong site surgery. Joint Commission Journal of Quality and Safety, 30 (7), 405-410. PMID: 15279505

    Alvarado, C.J., Carayon, P., & Hundt, A.S., (2004). Patient Safety Climate (PSC) in outpatient surgery centers. Proceedings of the Annual Meeting of the Human Factors and Ergonomics Society 48th Annual Meeting, New Orleans, LA.

    Carayon, P., Wetterneck, T.B., Hundt, A.S., Ozkaynak, M., Ram, P., DeSilvey, J., Hicks, B., Roberts, T.L., Enloe, M., Sheth, R. & Sobande, S. (2004). Assessing nurse interaction with medication administration technologies: The development of observation methodologies. In Khalid & Yeo (Eds.), Working with Computing Systems. Damai Sciences: Kuala Lumpar.

    Wetterneck, T.B., Skibinski, K., Schroeder, M., Roberts, T.L., & Carayon, P. (2004). Challenges with the performance of failure mode and effects analysis in healthcare organizations: An IV Medication Administration HFMEATM. Paper presented at the Annual Conference of the Human Factors and Ergonomics Society, New Orleans, LA.

    Karsh, B-T., Carayon, P., Smith, M., Skibinski, K., Thomadsen, B., Brennan, P. & Murray, M.E. (2004). The University of Wisconsin-Madison multidisciplinary graduate certificate in patient safety. In K. Henriksen, J.B. Battles, E. Marks, & D.I. Lewin (Eds.). Advances in Patient Safety: From Research to Implementation.

    Carayon, P., Hundt, A.S., Ayoub, P., Gurses, A., & Alvarado, C. (2003). Performance obstacles and facilitators of healthcare providers. VIIIth European Conference on Organizational Psychology and Health Care, Vienna, Italy.

    Hundt, A.S., Carayon, P., Ayoub, P. & Alvarado, C. (2003). Collecting workers’ perceptions of performance obstacles in outpatient surgery. Proceedings of the Human Factors and Ergonomics Society (HFES) 47th Annual Meeting, Denver, CO.

    Carayon, P., Bogsdorf, A., Ayoub, P., Hundt, A. & Alvarado, C. (2003). Making a community safer for patients: The development of the Madison Patient Safety Collaborative. Paper presented at the XVth Triennial Congress of the International Ergonomics Association, Seoul, Korea.

    Carayon, P., Alvarado, C., Hsieh, Y., & Hundt, A.S. (2003). A macroergonomic approach to patient process analysis: Application in outpatient surgery. Proceedings of the XVth Triennial Congress of the International Ergonomics Association, Seoul, Korea.

    Hundt, A.S., Carayon, P., Smith, P.D. & Kuruchittham, V. (2002). A macroergonomic case study assessing electronic medical record implementation in a small clinic. Proceedings of the Human Factors and Ergonomics Society (HFES) 46th Annual Meeting, Baltimore, MD.

    Carayon, P. & Smith, P. (2000). Evaluating the human and organizational aspects of Information Technology implementation in a small clinic. Proceedings of the Systems, Social and Internationalization Design Aspects of Human-Computer Interaction, pp. 903-907.

    Smith, M.J. & Carayon, P. (2000). Balance theory of job design. International Encyclopedia of Ergonomics and Human Factors. Karwowski, W. Taylor & Francis: London.

    Carayon, P. & Smith, M.J. (2000). Work organization and ergonomics. Applied Ergonomics, 31, 649-662.

Computerized Provider Order Entry in ICUs

3 Month Post-Implementation Questionnaire
12 Month Post-Implementation Questionnaire - Physicians
12 Month Post-Implementation Questionnaire - Nurses
Usability Evaluation Planning Document
Heuristic Evaluation Definitions and Data Collection Worksheet
Heuristic Evaluation Script
Specifications, Script, Data, Collection Tool for eMAR Usability Testing Evaluation
Slide presentation - Usability Principles and Methods
Slide presentation - Scenario-based Usability Evaluations

Health IT and Practice Redesign

Interview Guide for Clinicians and Office Staff
Clinician and Office Staff Survey
Pre-Visit Questionnaire
Patient Interview Guide

Keystone Beacon Community

Baseline Health Information Exchange Questionnaire - Clinicians
Beacon Clinician Questionnaire
Care Manager Questionnaire
Care Manager and Clinician Questionnaire
KBC Process Evaluation Questionnaire
Patient Satisfaction with Hospital Care Questionnaire
Case Manager Observation Guide
KBC MMA's Interview/Observation Guide
Care Coordination Interview Guide - Case Managers
Care Coordination Interview Guide - Others
Case Manager Interview Guide
Case Manager Final Interview Guide
KBC Management Team Interview Guide
Patient Satisfaction with KBC Care Management Interview Guide
KBC Care Manager Focus Groups Process
Patient Focus Group

Mychart Bedside

Parent Survey
MCB Pre-Implementation Survey
MCB Post-Implementation Survey

Nursing Work Obstacles

Performance Obstacles of ICU Nurses Questionnaire

Pediatric Family Centered Rounds

Children's Hospital Safety Climate Questionnaire
Family-Centered Rounds Toolkit

SAFE - C

Instructions for Nurses and MAs
Patient Scenarios to be used during training sessions
Physician Overview of the Patient Overview Process
Teamwork-Huddle Training
Training Evaluation

Patient Overview Document
Patient Overview Document with Sample Questions and Cues

Smart IV Pump Implementation

BCMA Observation Form
Pre-Implementation Pump Observation Guide
Post-Implementation Pump Observation Guide
Post-Pump Observation Interview Guide 
Usability Testing Script & Data Collection Guide  
Usability Testing Questionnaire - Anesthesiology
Usability Testing Questionnaire - Nursing 
Pre-Implementation Questionnaire 
3 Months Post-Implementation Questionnaire 
One Year Post-Implementation Questionnaire 
Team Evaluation Interview Guide 

Virtual ICU

Tele - ICU Characteristics Survey
Tele - ICU Observation & Interview Guide
Tele - ICU Manager Interview Guide
Tele - ICU Nurse Interview Guide
Tele - ICU Questionnaire

VTE and Health IT

VTE Prophylaxis Risk Assessment Tool Survey
Multidisciplinary Rounds Observation Tool