Health Care and Patient Safety – SEIPS – CQPI

The Systems Engineering Initiative for Patient Safety (SEIPS)

diagram — 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), 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, MS, Caprice Greenberg, MD, MPH, Amye Tevaarwerk, MD, Sharon Weber, MD, and Carla Pugh, MD, PhD; School of Nursing – Linsey Steege, PhD, Roger L. Brown, PhD, and Barbara King, PhD, RN; School of Pharmacy – Michelle Chui, PharmD, PhD; College of Engineering – Pascale Carayon, PhD, Douglas Wiegmann, PhD, Carla Alvarado, PhD, CIC, Mary Sesto, PhD, John Lee, PhD, Jingshan 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

Patient Safety Learning Lab (PSLL) [Funding by AHRQ]
Fluoroquinolones (FQ) Project

Past Projects

Teamwork and Care Transitions in Pediatric Trauma: Implications for Health IT Design
Bedside Notes: To examine the impact of implementing Bedside Notes [Funding by ICTR-CAP]
VTE and Health IT: Health IT process for preventing and managing venous thromboembolism (VTE) [Funding by AHRQ]
Implementation of Chlorhexidine Bathing to Reduce Healthcare-Associated Infections: The I-Care study
MyChart Bedside: Evaluate user experiences with MyChart Bedside, a new patient portal designed to improve quality and safety of care.
vizHome: Factors that influence a person’s ability to manage a health condition at home [Funding by AHRQ]
Improving Accessibility of Primary Care Delivery Through E-visits: Theory and Applications
Understanding Primary Care Teamwork in Context: Implication for HIT Design: Designing EHRs that support the cognitive work of clinicians [Funding by AHRQ]
Health IT Practice Redesign: Study on implementation of patient reported health IT with special attention to workflow [Funding by AHRQ]
Reducing Readmission After Complex Cancer Surgery [Funding by ICTR-CAP]
Keystone Beacon Community: Proposal for a rural community-wide medical home [Funding by ONC]
Pediatric Family-Centered Rounds: Engaging families in bedside rounds to promote pediatric patient safety [Funding by AHRQ]
Workflow Toolkit Analysis: Utility of the AHRQ workflow assessment toolkit in rural practice; [Funding by AHRQ]
SAFE – C: A human factors intervention to reduce risk in primary care of the elderly with situation awareness [Funding by AHRQ]
Proactive Risk Assessment: Primary care of the elderly
Assessing Risk in Ambulatory Medication Use After Hospital Transitions [Funding by AHRQ]
Virtual Intensive Care Units: Building and maintaining simultaneous dynamic relationships in a virtual organization [Funding by NSF]
Workflow Toolkit: Incorporating health information technology into workflow redesign [Funding by AHRQ]
HeartDecision: Computer decision support tools in primary care
Computerized Provider Order Entry (CPOE): Using human factors engineering to assess implementation of CPOE in ICUs [Funding by AHRQ]
Nursing, Technologies and Medication Management: New multidimensional measures of cost and quality [Funding by Robert Wood Johnson Foundation]
Nursing Work Obstacles: Assessing of workload, quality of working life and quality of care among ICU nurses [Funding by AHRQ]
Smart IV Pump Implementation: Safe medication administration through technologies and human factors [Funding by AHRQ]
Outpatient Surgery Interventions: Systems engineering intervention in outpatient surgery centers [Funding by AHRQ]
Small Clinic EMR Implementation
Training and Evaluation Project: Ultrasonic guidance for central venous cannulation
Bar Coding Technology: Patient and employee safety
The Value of CPOE in Pediatric Inpatient Units: Its Impact on Safety and Work [Funding by NLM]
A Macroergonomic Work System Analysis: Diagnostic testing for process improvement
Organizational Culture and Job Satisfaction: A study of family physicians

2020

Carayon, P., Kleinschmidt, P., Hose, B. and Salwei, M. (2020). Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical Residents. In: Textbook of Patient Safety and Clinical Risk Management. Donaldson, L., Ricciardi, W., Sheridan, S. and Tartaglia, R. (eds.).

Carayon, P., Wooldridge, A., Hoonakker, P.L.T., Hundt, A.S., Kelly, M.M. (2020). SEIPS 3.0: Human-Centered Design of the Patient Journey. Applied Ergonomics, 84, pp. 1-8. PMC7152782

Kianfar, S., Hundt, A.S., Hoonakker, P.L.T., Salek, D., Tomcavage, J., Wooldridge, A.R., Walker, J. and Carayon, P. “Understanding care transition notifications for chronically ill patients” Submitted to IISE Transaction on Healthcare Systems Engineering, 2020.

Musuuza, J., Hundt, A.S., Carayon, P., Zimbric, M.L., Schuetz, V., Reppen, M., Smith, W., Koffarnus,K., Brown, R.L., Roberts, T.J., Bowling, J., Jalali, K. and Safdar, N. “Implementing daily chlorhexidine gluconate treatment for the prevention of healthcare-associated infections in non-intensive care settings: A multiple case analysis” To be published in PLOS One, 2020. PMC7182260

Parmasad , V., Carayon, P. and Safdar, N. “Implementation of physical distancing for care delivery in healthcare settings” Submitted to Annals of Internal Medicine, 2020.

Pascale Carayon, Armagan Albayrak, Richard Goossens, Peter Hoonakker, Bat-Zion Hose, Michelle M. Kelly, Marijke Melles, Megan E. Salwei (2020). Macroergonomics of Patient Work: Engaging Patients in Improving Sociotechnical Context of Their Work. Chapter published in the Handbook on Patient Ergonomics (Richard Holden and Rupa Valdez, eds.).

Werner, N., Tong, M., Nathan-Roberts, D., Smith, C., Tredinnick, R., Ponto, K., Melles, M, Hoonakker, P.L.T. (2020). A sociotechnical systems approach toward tailored design for personal health information management. Patient Experience Journal 7(1), pp.75-83.

Wooldridge, A.R., Carayon, P, Hoonakker, P.L.T., Hose, B.-Z., Eithun, B.L., Brazelton, T.B., Ross, J.C., Kohler, J.E, Kelly, M.M., Dean, S.M., Rusy, D.A., Gurses, A.P. (2020, Online first). Work System Barriers and Facilitators in Inpatient Care Transitions of Pediatric Trauma Patients. Applied Ergonomics Special Issue on Care Transitions, Vol. 85, May 2020. https://doi.org/10.1016/j.apergo.2020.103059

2019

Carayon, P. & Hoonakker, P.L.T. (2019). Human Factors and Usability for Health Information Technology: Old and New Challenges. Chapter published in the IMIA 2019 Yearbook, pp. 71-77. PMC6697515

Carayon, P., Hoonakker, P.L.T., Hundt, A.S., Salwei, M., Wiegmann, D., Brown, R., Kleinschmidt, P., Novak, C., Pulia, M., Wang, Y., Wirkus, E., Patterson, B. (2019). Application of Human Factors to Improve Usability of CDS and Diagnostic Decision-Making. BMJ Quality & Safety: Epub ahead of print. http://dx.doi.org/10.1136/bmjqs-2019-009857

Carayon, P., Hundt, A.S, Hoonakker, P.L.T. (2019). Technology barriers and strategies in coordinating care for chronically ill patients. Applied Ergonomics 78(2019): 240-247. PMC6529186

Hoonakker, P.L.T., Carayon, P., Hose, B-Z, Ramsey, J., Eithun, B., Kim, M.K., Koffarnus, K.S., Kohler, J.E., Nieman, J.A., Reisman, M.M., Ross, J.C.,., Rusy, D.A., Soetenga, D.J., (2019). Proactive Risk Assessment of Team Health IT for Pediatric Trauma Care Transitions (T3). In: Health and Social Care Systems for the Future: Demographic Changes, Digital Age and Human Factors (Cotrim, T.P., Serranheira, F., Sousa, P., Hignett, S., Albolino, S., Tartaglia, R. (eds.)), pp. 213-221.

Hoonakker, P.L.T., Carayon, P., Salwei, M., Hundt, A.S., Wiegmann, D., Kleinschmidt, P., Patterson, B., Wang, Y., Novak, C. (2019). The Design of PE Dx, a CDS to Support Pulmonary Embolism Diagnosis in the ED. In: Context Sensitive Health Informatics: Sustainability in Dynamic Ecosystems (Marcilly, R., Kuziemsky, G., Nohr, C., Pelayo, S., eds.), pp. 134-140. PMC6900983

Hoonakker, P.L.T., Rankin, R., Passini, J., Bunton, J.A., Ehlenfeldt, B.D., Dean, S.M, Thurber, A.S., Kelly, M.M. (2019). Nurses expectations of an inpatient portal for hospitalized patients and caregivers. Applied Clinical Informatics 10, pp. 625-633. PMC6713574

Hoonakker, P.L.T., Wooldridge, A.R, Carayon, P., Hose, B.-Z., Eithun, B.L., Brazelton, T.B., Dean, S.M., Kelly, M.M., Kohler, J.E, Ross, J.C., Rusy, D.A., Gurses, A.P. (published online). Information Loss during Pediatric Trauma Care Transitions: Things Falling Through the Cracks. Paper published online in Internal and Emergency Medicine. https://doi.org/10.1007/s11739-019-02110-7

Hose, B.-T., Hoonakker, P., Wooldrige, A., Brazelton, T., Dean, S., Eithun, B., Fackler, J., Gurses, A.P., Kelly, M.M., Kohler, J.E., McGeorge, N., Ross, J., Rusy, D. and Carayon, P. Physician Perceptions of the Electronic Problem List in Pediatric Trauma Care. Appl Clin Inform, 10(1), 113-122. https://doi.org/10.1055/s-0039-1677737

Jolliff, A., Hoonakker, P.L.T., Ponto, K., Tredinnick, R., Casper, G., Martell, T., Werner, N.E. (2019). The Desktop or the Top of the Desk? The relative usefulness of household features for personal health information management. Applied Ergonomics 82, 102912. https://doi.org/10.1016/j.apergo.2019.102912

Kelly, M.M., Thurber, A.S., Coller, R.J., Khan, A., Dean, S.M., Smith, W., Hoonakker, P.L.T. (2019). Parent Perceptions of Real-time Access to Their Hospitalized Child’s Medical Records Using an Inpatient Portal: A Qualitative Study. Hospital Pediatrics, 9(4): 273-280. PMC6435002

Kelly, M.M., Xie, A., Li, Y., Cartmill, R., Cox, E.D., Brown, R.L., Wetterneck, T. and Carayon, P. “System factors influencing the use of a family-centered rounds checklist” To be published in Pediatrics Quality and Safety, 2019. PMC6708641

Kianfar, S., Carayon, P., Hundt, A.S., Hoonakker, P.L.T. (2019). Care coordination for chronically ill patients: Identifying coordination activities and interdependencies. Applied Ergonomics: 80:9-16. https://doi.org/10.1016/j.apergo.2019.05.002

Knobloch, M.J., Musuuza, J.S., McKinley, L., Zimbric, M.L., Baubie, K., Atherton, S., Pfund, A., Hagle, M., Rommelfaenger, M., Galea, M., Ferguson, M.R., Matteson, K.J., Dhein, J., Moore, M., Marx, D., Rick, D., Hundt, A.S., Pfeiffer, C.D., Crnich, C.J., Carayon, P., and Safdar, N. “Examining Factors Influencing Implementation of Chlorhexidine Gluconate (CHG) Bathing Treatment in Veterans Health Administration (VHA) Settings: The Human Factors Engineering to Prevent Resistant Organisms (HERO) project” Submitted to Implementation Science Communications, 2019.

Musuuza, J., Hundt, A.S., Carayon, P., Christensen, K., Ngam, C., Haun, N. and Safdar, N. “Implementation of a Clostridioides difficile prevention bundle: Understanding common, unique, and conflicting work system barriers and facilitators for sub-process design” To be published in Infection Control & Hospital Epidemiology, 2019. PMC7212912

Patterson, B.W., Pulia, M.S., Ravi, S., Hoonakker, P.L.T., Hundt, A.S., Wiegmann, D., Wirkus, E., Johnson, S., Carayon, P. (2019). Scope and Impact of EHR integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Annals of Emergency Medicine: 74(2):285-296. https://doi.org/10.1016/j.annemergmed.2018.10.034

Salwei, M.E., Carayon, P., Hundt, A.S., Hoonakker, P.L.T., Agrawal, V., Kleinschmidt, P., Stamm, J., Wiegmann, D., Patterson, B.W. (2019). Role network measures to assess healthcare team adaptation to complex situations: The case of venous thromboembolism prophylaxis. Ergonomics: 62(7): 864-879. PMC7243844

2018

Durojaiye, A.B., McGeorge, N.M., Puett, L.L., Stewart, D., Fackler, J.C., Hoonakker, P.L.T., Lehmann, H.P., Gurses, A.P. (2018). Mapping the flow of pediatric trauma patients using process mining on trauma registry data. Applied Clinical Informatics, 9 (3); pp. 654-666. https://doi.org/10.1055/s-0038-1668089.

Hoonakker, P.L.T. & Carayon, P. (2018). Work system barriers and strategies reported by tele-ICU nurses: a case study. Critical Care Nursing Clinics of North America, 30 (2), pp. 259-271. PMCID: PMC5942589

Hoonakker, P.L.T., Casper, G., Peer, A., Arnott Smith, C., Tredinnick, R., Werner, N., Ponto, K., (2018) Healthcare in a Virtual Environment: Workload and Simulation Sickness in a 3D CAVE. In: Bagnara S., Tartaglia R., Albolino S., Alexander T., Fujita Y. (eds) Proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), pp. 281-289. IEA 2018, Florence, Italy, August 26-30, 2018. Advances in Intelligent Systems and Computing, vol 822. Springer, Cham. https://doi.org/10.1007/978-3-319-96077-7_29

Hoonakker, P.L.T., Wooldridge, A.R, Carayon, P., Hose, B.-Z., Eithun, B.L., Brazelton, T.B., Dean, S.M., Kelly, M.M., Kohler, J.E, Ross, J.C., Rusy, D.A., Gurses, A.P (2019). Things Falling Through the Cracks: Information Loss During Pediatric Trauma Care Transitions. In: Bagnara S., Tartaglia R., Albolino S., Alexander T., Fujita Y. (eds) Proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), pp. 479-488. IEA 2018, Florence, Italy, August 26-30, 2018. Advances in Intelligent Systems and Computing, vol 818. Springer, Cham. https://doi.org/10.1007/978-3-319-96098-2_60

Hose BZ., Carayon, P., Hoonakker, P.L.T., Wooldridge, A.R, Brazelton, T.B., Eithun, B.L., Kelly, M.M., Dean, S.M., Eithun, B., Kelly, M., Kohler, J.C., Ross, J.E, Rusy, D.A., Gurses, A.P. (2018) Challenges of Disposition Decision Making for Pediatric Trauma Patients in the Emergency Department. In: Bagnara S., Tartaglia R., Albolino S., Alexander T., Fujita Y. (eds) Proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018). IEA 2018. Advances in Intelligent Systems and Computing, vol. 818. Springer, Cham. https://doi.org/10.1007/978-3-319-96098-2_44

Hundt, A.S., Carayon, P., Stamm, J., Agrawal, V., Hoonakker, P.L.T. (Accepted). Roles and responsibilities in the VTE prophylaxis process. Paper accepted for presentation at the IEA 2018, conference, Florence, Italy, August 26-30, 2018.

Joliff, A., Casper, G., Ponto, K., Hoonakker, P.L.T., Tredinnick, R., Martell, T., (Accepted). The perceived usefulness of household features for personal health information management. Paper accepted for presentation at the IEA 2018, conference, Florence, Italy, August 26-30, 2018.

Kelly, M.M., Coller, R., Dean, S., Thurber, A., Hoonakker, P.L.T. (2018). Offering hospitalized patients and families real-time, online access to their inpatient health record: Experiences across a Children’s Hospital” Paper presented at the Pediatric Academic Societies (PAS) 2018 Annual Meeting, May 5 – 8, Toronto, Canada.

Kelly, M.M., Coller, R.J., Hoonakker, P.L.T. (2018). Inpatient portals for hospitalized patients and caregivers: A systematic review. Journal of Hospital Medicine, 13 (6), pp. 405-412. PMID: 29261819

Salwei, M., Carayon, P., Hundt, A.S., Kleinschmidt, P., Hoonakker, P.L.T., Patterson, B.W., Wiegmann, D. (Accepted). Team adaptation to complex clinical situations: VTE prophylaxis in hospitalized patients. Paper accepted for presentation at the IEA 2018 conference, Florence, Italy, August 26-30, 2018.

Salwei M.E., Carayon, P., Hundt, A.S., Kleinschmidt, P., Hoonakker, P.L.T., Patterson, B.W., Wiegmann, D. (2018). Team Adaptation to Complex Clinical Situations: The Case of VTE Prophylaxis in Hospitalized Patients. In: Bagnara S., Tartaglia R., Albolino S., Alexander T., Fujita Y. (eds) Proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018), pp. 248-254. IEA 2018, Florence, Italy, August 26-30, 2018. Advances in Intelligent Systems and Computing, vol 818. Springer, Cham. https://doi.org/10.1007/978-3-319-96098-2_32

Salwei, M., Hoonakker, P.L.T., Hundt, A.S., Kleinschmidt, P., Novak, C., Patterson, B., Pulia, M., Wang, Y., Wiegmann, D., Wirkus, E., and Carayon, P. (2018). Using a Human Factors Approach to Design a Pulmonary Embolism Computer Decision Support Tool for the Emergency Department. Poster presented at the 26th Annual Wisconsin Emergency Medicine Research Forum, March 15, 2018, Madison, WI.

Salwei, M., Hundt, A.S., Carayon, P., Kleinschmidt, P., Hoonakker, P.L.T. (2018). EHR supported activities for VTE prophylaxis: A case study. Poster presented at the HFES Healthcare Conference, Boston, MA, March 26-28, 2018.

Wang, Y., Patterson, B., Ravi, S., Wiegmann, D., Hundt, A.S., Hoonakker, P.L.T., Kleinschmidt, P., Salwei, M., Wirkus, E., Carayon, P. (2018). EHR Flowchart of Information Search for Cues of PE Diagnosis in the ED. Poster presented at the 26^th Annual Wisconsin Emergency Medicine Research Forum, March 15, 2018, Madison, WI.

Wang, Y., Patterson, B., Ravi, S., Wiegmann, D., Hundt, A.S., Hoonakker, P.L.T., Kleinschmidt, P., Salwei, M., Wirkus, E., Carayon, P., (2018). Information Fragmentation in the Electronic Health Record: The Case of PE Diagnosis in the ED. Poster presented at the HFES Healthcare Conference, Boston, MA, March 26-28, 2018.

Wooldridge, A., Carayon, P., Eagan, B. and Shaffer, D.W. “Quantifying the qualitative with Epistemic Network Analysis: A human factors case study of task-allocation communication in a primary care team”, 2018, IIE Transactions on Healthcare Systems Engineering, 8(1): 72-82.

Wooldridge, A. R., Carayon, P., Hoonakker, P.L.T., Hose, B.-Z., Gurses, A. (Accepted for presentation). Redefining the Scope of the Care Transition Process: A Study of Pediatric Trauma Care Transitions. Paper accepted for presentation at the HFES conference, Philadelphia, PA, Oct 1-5, 2018.

Wooldridge, A.R, Carayon, P., Hoonakker, P.L.T., Hose, B.-Z., Ross, J.C., Kohler, J.E, Brazelton, T.B., Eithun, B.L., Kelly, M.M., Dean, S.M., Rusy, D.A., Durojaiye, A., Gurses, A.P. (Accepted). Complexity of the Pediatric Trauma Care Process: Implications for Multi-Level Awareness. Paper accepted for publication by Cognition, Technology and Work, https://doi.org/10.1007/s10111-018-0520-0

Yanke, E., Moriarty, H., Carayon, P. and Safdar, N. “The invisible staff”: a qualitative analysis of environmental service workers’ perceptions of the VA Clostridium difficile prevention bundle using a human factors engineering approach” Accepted for publication in the Journal of Patient Safety, 2018. PMC6800805

2017

Carayon, P., Wetterneck, T.B., Cartmill, R., Blosky, M.A., Brown, R.L., Hoonakker, P.L.T., Kim, R., Kukreja, S., Johnson, M., Paris, B.L., Wood, K.E., Walker, J.M. (2017). Medication Safety in Two ICUs of a Community Teaching Hospital after EHR Implementation. Journal of Patient Safety. PMCID: PMC5573668

Cox, E.D., Jacobsohn, G.C., Rajamanickam, V.P., Carayon, P., Kelly, M.M., Wetterneck, T.B., Rathouz, P.J. and Brown, R.L. (2017) A family-centered rounds checklist intervention, family engagement, and patient safety: A randomized trial. Pediatrics, 139(5).

Hoonakker, P.L.T., Carayon, P., Cartmill, R.S. (2017). The impact of secure messaging on workflow in primary care: Results of a multiple-case, multiple-method study. International Journal of Medical Informatics 100: pp. 63-76. PMID: 28241939

Hoonakker, P.L.T., Hundt, A.S., Asan, O., Valdez, R., Yang, Y. & Rivera, A.J. (2017). Designing Health Information Technology from a Human Factors Perspective. Proceedings of the ODAM conference, Banff, Canada, July 31-Aug 3, 2017, pp. 532-537.

Hoonakker, P.L.T., Pecanac, K.E., Brown, R.L. & Carayon, P. (2017). Virtual collaboration, satisfaction and trust between nurses in the tele-ICU and ICUs: Results of a multi-level analysis. Journal of Critical Care, 37: pp. 224-229 PMCID: PMC5168932

Hose, B-Z., Carayon, P., Hoonakker, P., Wooldridge, A.R., Ross, J., Kohler, J., Brazelton, T., Eithun, B., Kelly, M., Dean, S., Rusy, D., Gurses, A. (2017). Information Needs of Physicians in Pediatric Trauma. Poster presented at the Human Factors and Ergonomics in Healthcare, March 5-8, New Orleans, Louisiana.

Hundt, A.S., Carayon, P., Yang, Y., Stamm, J., Agrawal, V., Kleinschmidt, P, Hoonakker, P.L.T. (2017). Role Network Analysis of Team Interactions and Individual Activities: Application to VTE Prophylaxis Management. Proceedings of the HFES 2017 conference, Austin, TX, Oct 9-12, 2017, pp. 896-900.

Kelly, M.M., Dean, S.M., Carayon, P., Wetterneck, T.B., Hoonakker, P.L.T. (2017). Healthcare Team Perceptions of a Portal for Parents of Hospitalized Children Before and After Implementation. Applied Clinical Informatics 8 (1), pp. 265-278. PMCID: PMC5373769

Kelly, M.M., Hoonakker, P.L.T. & Dean, S. (2017). Using a patient portal to engage families in pediatric hospital care. JAMIA 24 (1) 153-161. PMID: 27301746

Kelly, M.M., Hoonakker, P.L.T. (2017). Getting on the same page: Opportunities to improve parent-provider communication. Hospital Pediatrics, 7, (9), 562-563. PMCID: PMC5574679

Kelly, M.M., Hoonakker, P.L.T., (2017). Parent experiences using a tablet computer to access their child’s hospital medical record. Paper presented at the PAS 2017 conference, May 7, 2017, San Francisco, CA.

Thurber, A., Hoonakker, P.L.T., Ehlenfeldt, B.D., Dean, S.M., Rankin, R.J., Byrne, B.J., Heatley, D.G., Bunton, J.A., Kelly, M.M., (2017). Implementation of a patient portal on a tablet computer across a children’s hospital. Poster presented at the 10th Annual Conference on the Science of Dissemination and Implementation in Health, Washington, DC, December 4-6, 2017.

Wooldridge, A. R., Carayon, P., Hoonakker, P., Hose, B.-Z., Ross, J., Kohler, J., Brazelton, T., Eithun, B., Kelly, M., Dean, S., Rusy, D., Gurses, A. (2017). Understanding Team Complexity in Pediatric Trauma Care. Human Factors and Ergonomics in Healthcare, March 5-8, New Orleans, Louisiana.

Wooldridge, A., Carayon, P. Hundt, A.S., Hoonakker, P.L.T. (2017). SEIPS-Based Process Modeling in Primary Care. Applied Ergonomics, 60, pp. 240-254. PMCID: PMC5308799

Wooldridge, A., Gurses, A., Carman, E.M., Waterson, P. Sesto, M., Hoonakker, P.L.T. (2017). Designing and managing healthcare transitions. Proceedings of the ODAM conference, Banff, Canada, July 31-Aug 3, 2017, pp. 538-542.

Zhong, X., Hoonakker, P.L.T., Bain, P.A., Musa, A.J. & Li, Y. (2017). Impact of E-Visits on Patient Access to Primary Care. Paper published online in Health Care Management Science. PMID: 28523477

2016

Carayon, P., Cartmill, R., Hoonakker, P.L.T., Hundt, A.S., Salek, D.,Walker, J., Tomcavage, J. (2016). Collaborative processes of care managers in the detection and recovery of medication errors. In Mollo, V. and Falzon, P. (Ed), Proceedings of the Healthcare Systems Ergonomics and Patient Safety Conference, Toulouse, France, October 5-7, 2016, pp. 87-92.

Hoonakker, P.L.T., Cartmill, R. & Carayon, P. (2016). Impact of electronic forms for patients on workflow in primary care. In Mollo, V. and Falzon, P. (Ed), Proceedings of the Healthcare Systems Ergonomics and Patient Safety Conference. Toulouse, France, October 5-7, 2016, pp. 190-195.

Hoonakker, P.L.T., Du, S., Hundt, A.S., Stamm, J., Patterson, B., Carayon, P., (2016). Perceived Effectiveness of Clinical Decision Support to Improve VTE Prophylaxis: A Comparison of Physicians, Pharmacists and Nurses. Poster presented at the AMIA conference, Chicago, IL, Nov 12-16, 2016. Poster was nominated for the AMIA Distinguished Poster Awards.

Hundt, A.S., Hoonakker, P.L.T., Agrawal, V., Stamm, J., Patterson, B. & Carayon, P. (2016). Triggers in VTE Prophylaxis from a Sociotechnical System Perspective. Poster presented at the AMIA conference, Chicago, IL, Nov 12-16, 2016.

Kelly, M., Hoonakker, P.L.T., Dean, S.M. (2016). The Impact of a Portal for Parents of Hospitalized Children on Healthcare Team Workflow. Poster presented at the AMIA conference, Chicago, IL, Nov 12-16, 2016.

Kelly, M.M., Dean, S., Byrne, B., Heatley, D., & Hoonakker, P.L.T. (2016). Improving medication safety through an inpatient portal for families of hospitalized children. In Mollo, V. and Falzon, P. (Ed), Proceedings of the Healthcare Systems Ergonomics and Patient Safety Conference. Toulouse, France, pp. 222-226.

Kelly, M.M., Hoonakker, P.L.T. & Dean, S. (2016). Using a patient portal to engage families in pediatric hospital care. JAMIA, 14 [epub ahead of print]. PMID: 27301746

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.

Li, Y., Carayon, P., Hundt, A.S., Hoonakker, P.L.T. (2016). Team interactions and health IT use during multidisciplinary rounds in three inpatient services. Proceedings of the HFES conference 2016, Washington DC, Sep 19-23, 2016, pp. 513-517.

McGeorge, Nicolette M., Durojaiye, Ashimiyu B., Fackler, James C., Xie, Anping, Rosen, Michael A., Hunt, Elizabeth A., Stewart, Dylan, Puett, Lisa L., Wooldridge, Abigail R., Carayon, Pascale, Hoonakker, Peter, Gurses, Ayse P. (2016). Pediatric Trauma Care Transitions: Understanding Teamwork for Health IT Design. Seventh Annual Johns Hopkins Medicine Patient Safety Summit: Working Together to Achieve Zero Preventable Harm, October, 2016, Baltimore, MD.

Patterson, B., Otles, E., Hundt, A.S., Hoonakker, P.L.T., & Carayon, P. (2016). Cues for VTE Diagnosis in the Emergency Department: A Sociotechnical Systems Approach for Clinical Decision Support. Poster presented at the AMIA conference, Chicago, IL, Nov 12-16, 2016. Poster was nominated for the AMIA Distinguished Poster Awards.

Werner, N.E., Carayon, P., Casper, G.R., Hoonakker, P.L.T., Arnott Smith, C., Brennan, P.F. (2016). Affordances of household features important for personal health information management: designing consumer health information technology for the home. In Mollo, V. and Falzon, P. (Ed), Proceedings of the Healthcare Systems Ergonomics and Patient Safety Conference. Toulouse, France, October 5-7, 2016, pp. 390-394.

Wooldridge, A.R., Carayon, P., Hoonakker, P.L.T., Musa, A., Bain, P. (2016). Technology-mediated communication between patients and primary care clinicians and staff: Ambiguity in secure messaging. Paper presented at the HFES conference 2016, Washington DC, Sep 19-23, 2016.

Zhong, X. Li, J., & Bain, P., Musa, A., Hoonakker, P.L.T. (2016). Improving Accessibility in Primary Care through E-visits. Paper presented at the 2016 IIE Annual Conference, May 21-24, 2016, Anaheim, CA.

2015

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. PMCID: PMC4279061

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. PMCID: PMC4530792

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. PMCID: PMC4490834

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, (ahead-of-print), 1-19. PMCID: PMC4618261

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. PMCID: PMC4185236

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. 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

2014

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.

2013

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. PMCID: PMC3724532

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.

2012

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.

2011

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.

2010

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.

2009

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.

2008

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.

2007

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. PMID: 17447667

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

2006

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.

2005

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.

2004

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.

2003

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.

2002

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.

2000

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 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