Figure 1.

Systems Engineering Initiative for Patient Safety (SEIPS) modelling of the work system, processes and outcomes for electronic fetal monitoring, with illustrative examples. The internal environment is the physical environment in the unit (its layout and architectural characteristics, including, for example, lighting and noise). The external environment covers contextual elements beyond the control of the organisation. Processes are aggregations of tasks into sequences of actions and decisions. Outcomes include those proximal (close in time) and distal (emerging later) that affect the people being cared for (here, the woman, the baby and possibly the partner), the professionals delivering care (here, midwives and doctors) and the organisation (the NHS trust). Adaptation describes how work system elements dynamically adjust to perceived gaps between actual and ideal outcomes. In this figure, the names of actors in the external environment reflect the situation of a site in England. Abbreviations: CQC: Care Quality Commission; CTG: cardiotocography; DHSC: Department of Health and Social Care; IT: information technology: NHS, National Health Service. See online supplemental file. This figure is based on Holden et al ²³ and Holden and Carayon.⁵¹