Table 5.

Key Systems Engineering Initiative of Patient Safety (SEIPS) Model Work System Themes and Illustrative Examples

Work System Element	Theme	Illustrative Quotation
Tools and Technology	Alerts: positive perceptions	“It’s become part of the normal process. I actually appreciate that it’s there because in the past, we just send C Diff, you know just not paying attention and over ordering.”—Nurse Practitioner, Hospital B
	Alert type: perception of hard stops	“..alerts are great. They remind you to look at things that you don’t always look up.” —Physician Assistant, Hospital C
	Human Computer Interface (Ease of use of Alert)	“I don’t find the alert to be disruptive because I like the idea of practicing appropriately. I don’t want to be that provider that’s doing inappropriate lab testing …. I think that it’s really valuable.” —Nurse Practitioner, Hospital D
Tasks	Complex Clinical Decision Making	“Clinical judgment of patient appearance is almost always the driver for me because otherwise, what am I doing, we can’t have an algorithm do everything in the hospital.” — Nurse Practitioner, Hospital D
		“..If I find out that there’s a clear reason like laxative use, I’m going to say no, the BPA is appropriate. Let’s hold off.” —Resident, Hospital A
	Workflow and communications	“I’ve got to say we don’t love alerts because they do interrupt, you’re already clicking a lot… but you feel, this is probably a good opportunity to make sure this is appropriate.” —Attending Physician, Hospital D
		“I don’t think it’s a significant stall in my workflow... I think that the BPA fits nicely into the workflow. It might delay my testing or… completing the workup for the patient a little bit. But I think it’s appropriately so.” —Physician Assistant, Hospital D
People	Attitudes regarding ordering autonomy	“… I should be able to order that if I think it’s indicated without needing further approval.” —Nurse Practitioner, Hospital D
		[If providers were presented with a hard stop] … “they would really think hard and fast, even hard and long before they order it.” —Nurse Practitioner, Hospital C
Organization	Different models of patient care continuity.	“In an academic center you are more likely to have continuity of care. Here, when you go off at 5:00 PM, the overnight provider knows nothing about the patient...if you’ve already tested for C. diff or if they’ve been on laxatives.” —Attending Physician, Hospital E
	Organizational cultures may be hierarchal	“This sort of thing can creep up in academic medicine where you’ve got the thought process of an intern not wanting to disappoint the attending, not thinking that this is an important enough issue to bug the attending about,….” —Attending Physician, Hospital E
		“Usually someone more senior on the team says, ‘Let’s send a C. diff’, and then we say, ‘Okay’. Yeah, I feel like if my attending told me to order it, then regardless I would order it.” —Resident, Hospital E