Human Factors in Organizational Design and Management VII 21

H. Luczak and K. J. Zink (Editors) 2003 All rights reserved.

Macroergonomics
in Quality of Care and Patient Safety

Pascale CARAYON
Systems Engineering Initiative for Patient Safety (SEIPS)
Center for Quality and Productivity Improvement & Department of Industrial Engineer-
ing; University of Wisconsin-Madison; Madison, WI USA

Abstract. Healthcare institutions can benefit from the models and

methods of macroergonomics in order to improve the quality and safety
of care provided.
Keywords. Macroergonomics, Healthcare, Quality of Care, Patient
Safety, Technology, System Design.

1. Introduction

Healthcare issues of importance vary from one country to the other, such as access to
healthcare, availability of healthcare professionals and healthcare facilities, access to
medication, etc All over the world, many countries are faced with issues of healthcare
cost, as well as the quality and safety of care provided. Much discussion on the quality
and safety of care has occurred in Australia (McNeil & Leeder, 1995) and the UK (UK
Department of Health, 2002). The US spends a large amount of its GDP on health care.
In 2000, healthcare expenditures represented more than 13% of the GDP (Agency for
Healthcare Research and Quality, 2002a). In the US, the 1999 publication of a report by
the Institute of Medicine has raised the level of awareness regarding medical errors and
patient safety (Kohn, Corrigan, & Donaldson, 1999). Discussion has occurred regarding
the number of medical errors in the American healthcare system and elsewhere. How-
ever, most agree that changes need to occur to improve the quality and safety of care
(Institute of Medicine Committee on Quality of Health Care in America, 2001). This
paper argues that healthcare institutions can benefit from the models and methods of
macroergonomics in order to improve the quality and safety of care provided.

2. Quality of Care and Patient Safety

The extent to which healthcare systems provide high-quality, safe care has been much
debated. A 2000 report published by the UK Department of Health provides some data
22

on the extent to which the English healthcare system fails to provide high-quality, safe
care (UK Department of Health, 2002). About 400 people die or are seriously injured in
adverse events involving medical devices. About 10,000 people report having experi-
enced serious adverse reactions to drugs. The UK National Health Service pays around
400 million a year for settlement of clinical negligence claims. Data for the US indi-
cates that Preventable adverse events are a leading cause of death in the United States
(Kohn et al., 1999). It has been suggested that at least 44,000 and perhaps as many as
98,000 Americans die in hospitals each year as a result of medical errors. Much debate
has occurred around the validity of those numbers (Leape, 2000). However, healthcare
experts and practitioners agree as to the necessity to redesign healthcare systems to im-
prove the quality and safety of care.
Quality of care has been conceptualized and assessed in a variety of manners. First,
the performance of a healthcare practitioner can be evaluated on two dimensions: (1)
technical performance that depends on the knowledge and judgment used to arrive at the
diagnostic and strategy of care and the skills in implementing the strategy; and (2) inter-
personal performance that emphasizes the relationship between the practitioner and the
patient (Donabedian, 1988). Second, the quality of care can be assessed at various lev-
els: care provided by a practitioner (e.g., physician, nurse) to an individual patient, care
provided by a healthcare institution (e.g., hospital, nursing home), care provided by a
health plan, care received by community, etc (Brook, McGlynn, & Cleary, 1996;
Donabedian, 1988). Third, quality of care can be evaluated on the basis of structure,
process, or outcome (Donabedian, 1988). According to Donabedian (1988), structure
relates to the attributes of the settings in which care occurs and includes material re-
sources, human resources and organizational structure. Process is defined as what is ac-
tually done in giving and receiving care, and outcome relates to the effects of care on
the health status of patients and populations. Debate is on-going as to whether struc-
tural, process or outcome measures of quality should be emphasized (Brook et al., 1996;
Clancy & Eisenberg, 1998).
Fourth, quality of care problems have been categorized into misuse (i.e. occurs
when an appropriate service has been selected but a preventable complication occurs
and the patient does not receive the full potential benefit of the service), overuse (i.e.
occurs when a health care service is provided under circumstances in which its poten-
tial for harm exceeds the potential benefit), and underuse (i.e. failure to provide a
health care service when it would have produced a favorable outcome for a patient)
(Chassin, Galvin, & The National Roundtable on Health Care Quality, 1998). According
to the 1999 IOM report (Kohn et al., 1999), issues of overuse and underuse should be
addressed by changing healthcare practices and achieving practices consistent with cur-
rent medical knowledge; and issues of misuse fit the patient safety concerns. However,
overuse and underuse can also be related to patient safety, such as too much care pro-
vided that put patient safety at risk or too little use of appropriate care that may decrease
unnecessary complications (Wakefield, 2001). According to AHRQ the goal of patient
safety is to reduce the risk of injury and harm from preventable medical errors, and ac-
cording to the IOM patient safety is freedom from accidental injury (Institute of Medi-
cine Committee on Quality of Health Care in America, 2001). Patient safety can be con-
sidered as one piece of the quality of health care puzzle (Institute of Medicine Commit-
tee on Quality of Health Care in America, 2001; Kohn et al., 1999; Wakefield, 2001).
The different approaches to quality of care and patient safety emphasize the charac-
teristics of the system (or structure) in which care processes occur and which lead to pa-
 23

tient outcomes. Therefore, macroergonomics has an important role to play in helping in

the human-centered design of systems and processes in order to achieve both positive
individual and organizational outcomes, as well as improved patient outcomes (im-
proved quality and safety of care) (Sainfort, Karsh, Booske, & Smith, 2001).

3. Human Factors in Healthcare

Recently, much emphasis has been put on human factors approaches to patient safety
(Bogner, 1994; Cook, Woods, & Miller, 1998; Leape, 1994; Wears & Perry, 2002). The
healthcare field has embraced the various models and approaches to human error in or-
der to analyze and evaluate risk and safety (Reason, 2000; Vincent, Taylor-Adams, &
Stanhope, 1998).
There is increasing recognition in the human error literature of the different levels of
factors that can contribute to human error and accidents (Rasmussen, 2000). If the vari-
ous factors are aligned appropriately like slices of Swiss cheese, accidents can occur
(Reason, 1990). Table 1 summarizes the different approaches to the levels of factors
contributing to human error. It is interesting to make a parallel between the different
levels of factors contributing to human error and the levels identified to deal with quality
and safety of care (Berwick, 2002; Institute of Medicine Committee on Quality of
Health Care in America, 2001). The 2001 IOM report on Crossing the Quality Chasm
defines four levels at which interventions are needed in order to improve the quality and
safety of care in the United States: Level A-experience of patients and communities,
Level B-microsystems of care, i.e. the small units of work that actually give the care that
the patient experiences, Level C-health care organizations, and Level D-health care en-
vironment. These levels are similar to the hierarchy of levels of factors contributing to
human error (see Table 1). Models and methods of macroergonomics can be particularly
useful because of their underlying system approach and capacity to integrate variables at
various levels (Hendrick, 1991; Luczak, 1997; Zink, 2000).
Human error models and approaches provide much information on how to under-
stand, analyze and evaluate near misses and accidents (Shojania, Wald, & Gross, 2002).
However, there is another large body of literature in human factors that has been rela-
tively ignored in the discussion on quality of care and patient safety. This body of litera-
ture (macroergonomics) provides much information on how to design and improve work
systems (Hendrick, 1997; Hendrick & Kleiner, 2001). Hendrick (1997) has defined a
number of levels of human factors or ergonomics:
human-machine: hardware ergonomics
human-environment: environmental ergonomics
human-software: cognitive ergonomics
human-job: work design ergonomics
human-organization: macroergonomics.
Research at the first three levels has been performed in the context of quality of care
and patient safety. Much still needs to be done at the levels of work design and at the
macroergonomic level in order to design healthcare systems that produce high-quality
safe patient care.
24

Table 1. Levels of Factors Contributing to Human Error.

AUTHORS
Rasmussen (2000): levels of a
complex socio-technical system
Moray (1994): hierarchical sys-
tems approach that includes sev-
eral layers
Johnson (2002): four levels of
causal factors that can contribute
to human error in healthcare
For comparison, levels of factors contribution to quality and safety of patient care
(Berwick, 2002; Institute of
Medicine Committee on Quality
of Health Care in America, 2001)
FACTORS CONTRIBUTING TO HUMAN ERROR
Work
Staff
Management
Company
Regulators/associations
Government
Physical device
Physical ergonomics
Individual behavior
Team and group behavior
Organizational and management behavior
Legal and regulatory rules
Societal and cultural pressures
Level 1 factors that influence the behavior of individual
clinicians (e.g., poor equipment design, poor ergonomics,
technical complexity, multiple competing tasks)
Level 2 factors that affect team-based performance (e.g.,
problems of coordination and communication, acceptance
of inappropriate norms, operation of different procedures
for the same tasks)
Level 3 factors that relate to the management of health-
care applications (e.g., poor safety culture, inadequate
resource allocation, inadequate staffing, inadequate risk
assessment and clinical audit)
Level 4 factors that involve regulatory and government
organizations (e.g., lack of national structures to support
clinical information exchange and risk management).
Level A experience of patients and communities
Level B microsystems of care, i.e. the small units of
work that actually give the care that the patient experi-
ences
Level C health care organizations
Level D health care environment

4. Technology in Healthcare
In healthcare, technologies are often seen as an important solution to improve quality of
care and reduce or eliminate medical errors (Bates & Gawande, 2003; Kohn et al.,
1999). These technologies include organizational and work technologies aimed at im-
proving the efficiency and effectiveness of information and communication processes
(e.g., computerized order entry provider systems and electronic medical record systems)
and patient care technologies that are directly involved in the care processes (e.g., bar
code technology for medication administration). For instance, the 1999 IOM report rec-
ommended adoption of new technology, like bar code administration technology, to re-
duce medication errors (Kohn et al., 1999). However, implementation of new technolo-
gies in health care has not been without troubles or work-arounds (see, for example, the
study of Patterson and colleagues (2002) on the side effects of bar code medication ad-
 25

ministration technology). Technologies can change the way work is being performed
and because healthcare work and processes are complex, negative consequences of new
technologies are possible (Cook, 2002).
When looking for solutions to improve patient safety, technology may or may not be
the only solution. For instance, a study of the implementation of nursing information
computer systems in 17 New Jersey hospitals showed many problems experienced by
hospitals, such as delays, and lack of software customization (Hendrickson, Kovner,
Knickman, & Finkler, 1995). On the other hand, at least initially, nursing staff reported
positive perceptions, in particular with regard to documentation (more readable, com-
plete and timely). However, a more scientific quantitative evaluation of the quality of
nursing documentation following the implementation of bedside terminals did not con-
firm those initial impressions (Marr et al., 1993). This later result was due to the low use
of bedside terminals by the nurses. This technology implementation may have ignored
the impact of the technology on the tasks performed by the nurses. Nurses may have
needed time away from the patients bedside in order to organize their thoughts and col-
laborate with colleagues (Marr et al., 1993). This study demonstrates the need for a mac-
roergonomic approach to understand the impact of technology. For instance, instead of
using the leftover approach to function and task allocation, a human-centered ap-
proach to function and task allocation should be used (Hendrick & Kleiner, 2001). This
approach considers the simultaneous design of the technology and the work system in
order to achieve a balanced work system. One possible outcome of this allocation ap-
proach would be to rely on human and organizational characteristics that can foster
safety (e.g., autonomy provided at the source of the variance; human capacity for error
recovery), instead of completely trusting the technology to achieve high quality and
safety of care.
Whenever implementing a technology, one should examine the potential positive
AND negative influences of the technology on the other work system elements (Battles
& Keyes, 2002; Kovner, Hendrickson, Knickman, & Finkler, 1993; Smith & Carayon-
Sainfort, 1989). In a study of the implementation of an Electronic Medical Record
(EMR) system in a small family medicine clinic, a number of issues were examined:
impact of the EMR technology on work patterns, employee perceptions related to the
EMR technology and its potential/actual effect on work, and the EMR implementation
process (Carayon & Smith, 2001). Employee questionnaire data showed the following
impact of the EMR technology on work. Increased dependence on computers was found,
as well as an increase in quantitative workload and a perceived negative influence on
performance occurring at least in part from the introduction of the EMR (Hundt,
Carayon, Smith, & Kuruchittham, 2002). It is important to examine for what tasks tech-
nology can be useful to provide better, safer care (Hahnel, Friesdorf, Schwilk, Marx, &
Blessing, 1992).
The human factors characteristics of the new technologies design should also be
studied carefully (Battles & Keyes, 2002). An experimental study by Lin et al. (2001)
showed the application of human factors engineering principles to the design of the in-
terface of an analgesia device. Results showed that the new interface led to the elimina-
tion of drug concentration errors, and to the reduction of other errors. A study by Effken
et al. (1997) shows the application of a human factors engineering model, i.e. the eco-
logical approach to interface design, to the design of a haemodynamic monitoring de-
vice. Whereas micro-ergonomics has been applied to technology design in healthcare,
macroergonomics has not been applied yet. Luczak (1995) proposed a method for con-
26

sidering macroergonomics early in the phase of system design. This method has been
applied to manufacturing production systems. The question remains of how macroergo-
nomic anticipatory design can be performed to create safe healthcare systems.
The new technology may also bring its own forms of failure (Battles & Keyes,
2002; Cook, 2002; Reason, 1990). For instance, bar coding technology can prevent pa-
tient misidentifications, but the possibility exists that an error during patient registration
may be disseminated throughout the information system and may be more difficult to
detect and correct than with conventional systems (Wald & Shojania, 2001).
In addition, the manner in which a new technology is implemented is as critical to its
success as its technological capabilities (see for example Eason (1982), and Smith and
Carayon (1995)). End user involvement in the design and implementation of a new
technology is a good way to help ensure a successful technological investment. Korunka
and his colleagues (Korunka & Carayon, 1999; Korunka, Weiss, & Karetta, 1993;
Korunka, Zauchner, & Weiss, 1997) have empirically demonstrated the crucial impor-
tance of end user involvement in the implementation of technology to the health and
well-being of end users. The implementation of technology in an organization has both
positive and negative effects on the job characteristics that ultimately affect individual
outcomes (quality of working life, such as job satisfaction and stress; and perceived
quality of care delivered or self-rated performance) (Carayon and Haims, 2001). Inade-
quate planning when introducing a new technology designed to decrease medical errors
has led to technology falling short of achieving its patient safety goal (Kaushal & Bates,
2001; Patterson et al., 2002). The most common reason for failure of technology imple-
mentations is that the implementation process is treated as a technological problem, and
the human and organizational issues are ignored or not recognized (Eason, 1988). When
a technology is implemented, several human and organizational issues are important to
consider (Carayon-Sainfort, 1992; Smith & Carayon, 1995). More macroergonomic
knowledge needs to be applied to the implementation of technologies in healthcare.

5. Macroergonomic Design and Redesign in Healthcare

A question raised by ergonomists is how to ensure that ergonomic criteria are considered
in the early stage of work system design (Clegg, 1988; Luczak, 1995; Slappendel, 1994).
Johnson and Wilson (1988) discuss two approaches for taking into account ergonomics
in work system development: (1) provision of guidelines, and (2) ergonomics input
within collaborative design. In order to define macroergonomic guidelines, we need to
better understand the specific work system elements (and their combinations) that affect
the outcomes of quality and safety of health care. We have limited information on this.
The other strategy proposed by Johnson and Wilson can be more rapidly implemented.
This necessitates the close collaboration of macroergonomists and healthcare profes-
sionals at various stages of work system design. Three different stages of work system
development can be distinguished (Clegg, 1988):
1. design of work system
2. implementation of work system
3. operation of work system.
 27

5.1 Phase of Work System Design

Ergonomic criteria should be considered as early as possible. Unfortunately, very little

research has been conducted to examine how ergonomic criteria are considered in the
design of new work systems. Wulff and her colleagues (1999a; 1999b) have conducted a
study of the implementation of ergonomics requirements in large-scale engineering pro-
jects of the design of off-shore installations. Exploratory case studies in two engineering
design companies involved in two different design projects were conducted. Consider-
able resistance to using ergonomic requirements in their design was observed within the
engineering teams. A reason for the resistance appeared to be the lack of familiarity with
this new set of requirements in combination with high total workload. A solution to this
problem may be to include an active ergonomics resource person in the design organi-
zation. When an ergonomist with high legitimacy was actively involved in the design
process, ergonomics requirements were more likely to be used. In addition, organiza-
tional means can be used to ensure the implementation of ergonomic criteria in the de-
sign process. Examples of organizational means include: emphasis on ergonomics in
general company policy documents, high organizational status for ergonomics, and ac-
tive support of senior management. How does this research translate to the design of
work systems in healthcare in order to achieve high-quality, safe patient care? This
raises issues regarding the availability of human factors expertise within healthcare insti-
tutions, as well as the need for resources allocated to ensure that ergonomic criteria are
considered as the work system design stage.
Clegg (1988) argues that organizations have many choices when they design manu-
facturing systems. Decisions are made regarding the following factors:
the type and level of technology. Different elements can impact decisions regarding
the type and level of technology: resources available, expected return on investment,
technology push.
the allocation of functions between humans and machines. In general, the human
aspect is considered late in the design of manufacturing systems, therefore leaving
the leftover tasks to people.
the roles of humans in the system. Once allocation of function decisions have been
made, the various tasks need to be organized into job designs for the future operators
of the system.
the organizational structures to support workers. Companies who are introducing
new manufacturing systems could usefully ask themselves what organizational
structures are appropriate.
the way in which people participate in their design. The type, extent and timing of
worker participation in the design of work systems are all important aspects to con-
sider (Smith & Carayon, 1995).
Choices made regarding these different issues have important ergonomic and health
implications. Similar choices are made by healthcare organizations when designing
work systems and structures, patient care processes, as well as other processes. How do
we ensure that designers of healthcare work system and technologies take into account
ergonomics, in particular macroergonomics?
One example of work system design is the construction of a new health care facility.
Health care facility construction, whether a new building or an expansion of an existing
medical center, can present a number of challenges and a number of opportunities, not
the least of which is improving working conditions, quality of care and patient safety.
28

However, a far-sighted health care facility in West Bend, Wisconsin is demonstrating

that new construction projects actually present an opportunity to improve working con-
ditions and patient safety. In April 2000, St. Josephs Community Hospital of West
Bend, Wisconsin, a member of SynergyHealth Inc., started focusing on how the design
of a new facility could affect patient safety. A participatory learning laboratory devel-
oped recommendations that St. Josephs could apply in the design process (Reiling &
Chernos, 2004). St. Josephs facility design process for patient safety is an interesting
case study. However, more needs to be learned about how ergonomics knowledge (in-
cluding macroergonomics) can be integrated at the stage of healthcare system design.

5.2 Phase of Implementation

In the phase of work system implementation, the question arises as to the methods and
processes to use in order to facilitate the change process, and rapidly achieve the ex-
pected outcomes (i.e. improved quality and safety of care). The way change is imple-
mented (i.e. process implementation) is central to the successful adaptation of organiza-
tions to changes. A successful work system implementation from the human factors
viewpoint is defined by its human and organizational characteristics: reduced/limited
negative impact on people (e.g., stress, dissatisfaction, etc.) and on the organization (de-
lays, costs, medication errors, etc.), and increased positive impact on people (e.g., accep-
tance of change, job control, enhanced individual performance) and on the organization
(e.g., efficient implementation process, safe patient care). Success also includes decreas-
ing medical errors and improving quality of care. Several authors have recognized the
importance of the process of implementation in achieving a successful organizational
change (Tannenbaum et al., 1996; Korunka et al., 1993).
Participatory ergonomics is a powerful method for implementing work system
changes (Wilson, 1995). Participation has been used as a key method for implementing
various types of organizational changes, such as ergonomic programs (Wilson & Haines,
1997), continuous improvement programs (Zink, 1996) and technological change
(Carayon & Karsh, 2000; Eason, 1988). Noro and Imada (1991) define participatory er-
gonomics as a method in which end-users of ergonomics (workers, nurses) take an ac-
tive role in the identification and analysis of ergonomic risk factors as well as the design
and implementation of ergonomic solutions. Evanoff and his colleagues have conducted
studies on participatory ergonomics in health care (Bohr, Evanoff, & Wolf, 1997; Evan-
off, Bohr, & Wolf, 1999). One study examined the implementation of participatory er-
gonomics teams in a medical center. Three groups participated in the study: a group of
orderlies from the dispatch department, a group of intensive care unit (ICU) nurses, and
a group of laboratory workers. Overall, the team members for the dispatch and the labo-
ratory groups were satisfied with the participatory ergonomics process, and these per-
ceptions seem to improve over time. However, the ICU team members expressed more
negative perceptions. The problems encountered by the ICU team seem to be related to
the lack of time and the time pressures due to the clinical demands. A more in-depth
evaluation of the participatory ergonomics program on orderlies showed substantial im-
provements in health and safety following the implementation of the participatory ergo-
nomics program (Evanoff et al., 1999). The studies by Evanoff and colleagues demon-
strate the feasibility of implementing participatory ergonomics in health care, but high-
light the difficulty of the approach in a high-stress, high-pressure environment, such as
 29

an intensive care unit, where patient needs are critical and patients need immediate or
continuous attention. More research is needed in order to develop macroergonomic
methods for implementing work system changes that lead to improvements in human
and organizational outcomes, as well as improved quality and safety of care. This re-
search should consider the high-pace, high-pressure work environment of healthcare.
The implementation of any new work system always engenders problems and con-
cerns. The process by which these problems and concerns are resolved is important from
a human factors point of view, but also from a quality of care and patient safety point of
view. It is necessary to have the capability and tools to identify potential human factors,
and quality and safety of care problems in a timely manner.

5.3 Operational Phase

During the operational phase, the new work system is in place. What are the characteris-
tics of a work system that lead to quality of care and patient safety? Much work is
needed to specify the structural component of quality of care. For instance, what work-
ing conditions are related to quality of care? Much is known about the working condi-
tions that affect stress, job satisfaction and other human outcomes (Kalimo, Lindstrom,
& Smith, 1997; Smith, 1987). However, we need to know more about the working con-
ditions that affect quality and safety of care, and more importantly how to improve
working conditions in order to improve both human outcomes (e.g., reduced stress, in-
creased job satisfaction and reduced injuries) and patient outcomes. Some of the patient
safety research funded by the American Agency for Healthcare Research and Quality
(AHRQ) addresses this issue (Agency for Healthcare Research and Quality, 2002b).
Workload is one working condition of particular importance in healthcare quality
and safety. For instance, Tarnow-Mordi et al. (2000) examined the relationship between
mortality rates and the workload of hospital staff in one adult ICU in the United King-
dom. The measures of ICU workload most strongly associated with mortality were: peak
occupancy, average nursing requirement per occupied bed per shift, and the ratio of oc-
cupied to appropriately staffed beds. This study illustrates the current approach to work-
load and patient safety: workload is typically measured at the unit level (e.g., an ICU).
Such level of analysis does not reveal the system design characteristics that may con-
tribute to workload and patient safety problems. In the previous study, explanations for
the association between high workload and mortality highlighted several system charac-
teristics, such as insufficient time for clinical procedures to be done appropriately, in-
adequate training or supervision, errors, overcrowding and consequently nosocomial
infections, limited availability of equipment, and premature discharge from the ICU.
Macroergonomic conceptualization and assessment of workload would reveal the
sources of workload, and help identify ways of redesigning the work system to reduce
workload and improve patient safety.
How does one ensure that continuous improvements in work system design and im-
portant outcomes (quality of care and patient safety, as well as human and organiza-
tional outcomes) are achieved? Various models and approaches to quality improvement
and management have been proposed and implemented in healthcare (for example,
Shortell et al., 1995). This research would benefit from a macroergonomic point of view
in order to simultaneously optimize work system design and improve quality and safety
of care. Macroergonomic approaches to quality management and improvement have
30

emphasized the importance of job and organizational design and quality of working life
(Carayon, Sainfort, & Smith, 1999), the link between ergonomic deficiencies and quality
deficiencies (Axelsson, 2000; Eklund, 1995), and the importance of management ap-
proaches for improved safety and health (Zink, 2000). All of these macroergonomic ap-
proaches have much to offer to designing continuous improvement systems and proc-
esses in healthcare. The goal of the improvement systems and processes would be to
improve human and organizational outcomes, and as well as quality of care and patient
safety.
There is much debate around the quality and safety of healthcare, the extent of the prob-
lem, and its associated costs. The recent surge in interest in patient safety probably
stems from various reasons, including the sheer desire to improve quality and safety of
health care, media interest, public opinion, and insurance and litigation costs (Johnson,
2002). Much human factors research has been performed in healthcare. In particular,
emphasis has been put on human error and its application to the understanding of patient
safety. Macroergonomics is another important piece of the human factors and ergonom-
ics discipline that has much to contribute to patient safety, in particular with regard to
system improvement. However, there is still much that needs to be learned, especially
regarding macroergonomics knowledge and tools applied to quality of care and patient
safety.

6. Acknowledgements

Funding for the SEIPS (Systems Engineering Initiative for Patient Safety) project is
provided by the Agency for Healthcare Research and Quality (Principal Investigator:
P. Carayon, Grant # P20 HS11561-01).

7. References

1. Agency for Healthcare Research and Quality. (2002a). Health Care Costs. Fact Sheet (AHRQ
Publication No. 02-P033). Rockville, MD.: Agency for Healthcare Research and Quality.
2. Agency for Healthcare Research and Quality. (2002b). Impact of Working Conditions on Pa-
tient Safety (AHRQ Publication No. 03-P003). Rockville, MD: Agency for Healthcare Re-
search and Quality.
3. Axelsson, J. R. C. (2000). Quality and Ergonomics - Towards Successful Integration. Unpub-
lished Ph.D. Dissertation, Linkoping University, Linkoping, Sweden.
4. Bates, D. W., & Gawande, A. A. (2003). Improving safety with information technology. The
New England Journal of Medicine, 348 (25), 2526-2534.
5. Battles, J. B., & Keyes, M. A. (2002). Technology and patient safety: A two-edged sword.
Biomedical Instrumentation & Technology, 36 (2), 84-88.
6. Berwick, D. M. (2002). A user's manual for the IOM's 'Quality Chasm' report. Health Affairs,
21 (3), 80-90.
7. Bogner, M. S. (Ed.). (1994). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum
Associates.
 31

8. Bohr, P. C., Evanoff, B. A., & Wolf, L. (1997). Implementing participatory ergonomics teams
among health care workers. American Journal of Industrial Medicine, 32, 190-196.
9. Brook, R. H., McGlynn, E. A., & Cleary, P. D. (1996). Quality of health care. Part 2: Measur-
ing quality of care. New England Journal of Medicine, 335 (13), 966-970.
10. Carayon, P., & Karsh, B. (2000). Sociotechnical issues in the implementation of imaging tech-
nology. Behaviour and Information Technology, 19 (4), 247-262.
11. Carayon, P., Sainfort, F., & Smith, M. J. (1999). Macroergonomics and Total Quality Man-
agement: How to improve quality of working life? International Journal of Occupational
Safety and Ergonomics, 5 (2), 303-334.
12. Carayon, P., & Smith, P. D. (2001). Evaluating the human and organizational aspects of infor-
mation technology implementation in a small clinic. In M. J. Smith & G. Salvendy (Eds.), Sys-
tems, Social and Internationalization Design Aspects of Human-Computer Interaction (pp.
903-907). Mahwah, NJ: Lawrence Erlbaum Associates.
13. Carayon-Sainfort, P. (1992). The use of computers in offices: Impact on task characteristics
and worker stress. International Journal of Human Computer Interaction, 4 (3), 245-261.
14. Chassin, M. R., Galvin, R. W., & The National Roundtable on Health Care Quality. (1998).
The urgent need to improve health care quality. Journal of the American Medical Association,
280 (11), 1000-1005.
15. Clancy, C. M., & Eisenberg, J. M. (1998). Outcomes research: Measuring the end results of
health care. Science, 282 (5387), 245-246.
16. Clegg, C. (1988). Appropriate technology for manufacturing: Some management issues. Ap-
plied Ergonomics, 19 (1), 25-34.
17. Cook, R. I. (2002). Safety technology: Solutions or experiments? Nursing Economic$, 20 (2),
80-82.
18. Cook, R. I., Woods, D. D., & Miller, C. (1998). A Tale of Two Stories: Contrasting Views of
Patient Safety. Chicago, IL: National Patient Safety Foundation.
19. Donabedian, A. (1988). The quality of care. How can it be assessed? Journal of the American
Medical Association, 260 (12), 1743-1748.
20. Eason, K. (1988). Information Technology and Organizational Change. London: Taylor &
Francis.
21. Eason, K. D. (1982). The process of introducing information technology. Behaviour and In-
formation Technology, 1 (2), 197-213.
22. Effken, J. A., Kim, M.-G., & Shaw, R. E. (1997). Making the constraints visible: Testing the
ecological approach to interface design. Ergonomics, 40 (1), 1-27.
23. Eklund, J. A. E. (1995). Relationships between ergonomics and quality in assembly work. Ap-
plied Ergonomics, 26 (1), 15-20.
24. Evanoff, V. A., Bohr, P. C., & Wolf, L. (1999). Effects of a participatory ergonomics team
among hospital orderlies. American Journal of Industrial Medicine, 35, 358-365.
25. Hahnel, J., Friesdorf, W., Schwilk, B., Marx, T., & Blessing, S. (1992). Can a clinician predict
the technical equipment a patient will need during intensive care unit treatment? An approach
to standardize and redesign the intensive care unit workstation. Journal of Clinical Monitoring,
8 (1), 1-6.
26. Hendrick, H. W. (1991). Human factors in organizational design and management. Ergonom-
ics, 34, 743-756.
32

27. Hendrick, H. W. (1997). Organizational design and macroergonomics. In G. Salvendy (Ed.),

Handbook of Human Factors and Ergonomics (pp. 594-636). New York: John Wiley & Sons.
28. Hendrick, J. W., & Kleiner, B. M. (2001). Macroergonomics - An Introduction to Work System
Design. Santa Monica, CA: The Human Factors and Ergonomics Society.
29. Hendrickson, G., Kovner, C. T., Knickman, J. R., & Finkler, S. A. (1995). Implementation of a
variety of computerized bedside nursing information systems in 17 New Jersey hospitals.
Computers in Nursing, 13 (3), 96-102.
30. Hundt, A. S., Carayon, P., Smith, P. D., & Kuruchittham, V. (2002). A macroergonomic case
study assessing Electronic Medical Record implementation in a small clinic. Paper presented at
the Human Factors and Ergonomics Society 46th Annual Meeting, Baltimore, Maryland.
31. Institute of Medicine Committee on Quality of Health Care in America. (2001). Crossing the
Quality Chasm: A New Health System for the 21st. Washington, DC: National Academy Press.
32. Johnson, C. (2002). The causes of human error in medicine. Cognition, Technology & Work, 4,
65-70.
33. Johnson, G. I., & Wilson, J. K. (1988). Future directions and research issues for ergonomics
and advanced manufacturing technology (AMT). Applied Ergonomics, 191 (3-8).
34. Kalimo, R., Lindstrom, K., & Smith, M. J. (1997). Psychosocial approach in occupational
health. In G. Salvendy (Ed.), Handbook of Human Factors and Ergonomics (pp. 1059-1084).
New York: John Wiley & Sons.
35. Kaushal, R., & Bates, D. W. (2001). Chapter 6. Computerized Physician Order Entry (CPOE)
with Clinical Decision Support Systems (CDSSs). In K. G. Shojania & B. W. Duncan & K. M.
McDonald & R. M. Wachter (Eds.), Making health care safer: A critical analysis of patient
safety practices (Vol. Evidence Report/Technology Assessment, pp. 59-69): AHRQ Publica-
tion.
36. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (1999). To Err is Human: Building a
Safer Health System. Washington, D.C.: National Academy Press.
37. Korunka, C., & Carayon, P. (1999). Continuous implementations of information technology:
The development of an interview guide and a cross-national comparison of Austrian and
American organizations. The International Journal of Human Factors in Manufacturing, 9 (2),
165-183.
38. Korunka, C., Weiss, A., & Karetta, B. (1993). Effects of new technologies with special regard
for the implementation process per se. Journal of Organizational Behavior, 14 (4), 331-348.
39. Korunka, C., Zauchner, S., & Weiss, A. (1997). New information technologies, job profiles,
and external workload as predictors of subjectively experienced stress and dissatisfaction at
work. International Journal of Human-Computer Interaction.
40. Kovner, C. T., Hendrickson, G., Knickman, J. R., & Finkler, S. A. (1993). Changing the deliv-
ery of nursing care - Implementation issues and qualitative findings. Journal of Nursing Ad-
ministration, 23 (11), 24-34.
41. Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association, 272 (23),
1851-1857.
42. Leape, L. L. (2000). Institute of Medicine medical error figures are not exaggerated. JAMA,
284 (1), 95-97.
43. Lin, L., Vicente, K. J., & Doyle, D. J. (2001). Patient safety, potential adverse drug events, and
medical device design: A human factors engineering approach. Journal of Biomedical Infor-
matics, 34 (4), 274-284.
 33

44. Luczak, H. (1995). Macroergonomic anticipatory evaluation of work organization in produc-

tion systems. Ergonomics, 38 (8), 1571-1599.
45. Luczak, H. (1997). Task analysis. In G. Salvendy (Ed.), Handbook of Human Factors and Er-
gonomics (Second ed., pp. 340-416). New York: John Wiley & Sons.
46. Marr, P. B., Duthie, E., Glassman, K. S., Janovas, D. M., Kelly, J. B., Graham, E., Kovner, C.
T., Rienzi, A., Roberts, N. K., & Schick, D. (1993). Bedside terminals and quality of nursing
documentation. Computers in Nursing, 11 (4), 176-182.
47. McNeil, J. J., & Leeder, S. R. (1995). How safe are Australian hospitals? Medical Journal of
Australia, 163 (6), 472-475.
48. Moray, N. (1994). Error reduction as a systems problem. In M. S. Bogner (Ed.), Human Error
in Medicine (pp. 67-91). Hillsdale, NJ: Lawrence Erlbaum Associates.
49. Noro, K., & Imada, A. (1991). Participatory Ergonomics. London: Taylor & Francis.
50. Patterson, E. S., Cook, R. I., & Render, M. L. (2002). Improving patient safety by identifying
side effects from introducing bar coding in medication administration. Journal of the American
Medial Informatics Association, 9, 540-553.
51. Rasmussen, J. (2000). Human factors in a dynamic information society: Where are we head-
ing? Ergonomics, 43 (7), 869-879.
52. Reason, J. (1990). Human Error. Cambridge: Cambridge University Press.
53. Reason, J. (2000). Human error: models and management. British Medical Journal,
320 (7237), 768-770.
54. Reiling, J., & Chernos, S. (2004). Error reduction through facility design. In M. S. Bogner
(Ed.), Human Error in Healthcare: A Handbook of Issues and Indications (pp. to be pub-
lished). Mahwah, NJ: Lawrence Erlbaum Associates.
55. Sainfort, F., Karsh, B., Booske, B. C., & Smith, M. J. (2001). Applying quality improvement
principles to achieve healthy work organizations. Journal on Quality Improvement, 27 (9),
469-483.
56. Shojania, K. G., Wald, H., & Gross, R. (2002). Understanding medical error and improving
patient safety in the inpatient setting. Medical Clinics of North America, 86 (4), 847-867.
57. Shortell, S. M., O'Brien, J. L., Carman, J. M., Foster, R. W., Hughes, E. F. X., Boerstler, H., &
O'Connor, E. J. (1995). Assessing the impact of continuous quality improvement/total quality
management: Concept versus implementation. Health Services Research, 30 (2), 377-401.
58. Slappendel, C. (1994). Ergonomics capability in product design and development: An organ-
izational analysis. Applied Ergonomics, 25 (5), 266-274.
59. Smith, M. J. (1987). Occupational stress. In G. Salvendy (Ed.), Handbook of Human Factors
and Ergonomics (pp. 844-860). New York: John Wiley & Sons.
60. Smith, M. J., & Carayon, P. (1995). New technology, automation, and work organization:
Stress problems and improved technology implementation strategies. The International Jour-
nal of Human Factors in Manufacturing, 5 (1), 99-116.
61. Smith, M. J., & Carayon-Sainfort, P. (1989). A balance theory of job design for stress reduc-
tion. International Journal of Industrial Ergonomics, 4, 67-79.
62. Tarnow-Mordi, W. O., Hau, C., Warden, A., & Shearer, A. J. (2000). Hospital mortality in
relation to staff workload: a 4-year study in an adult intensive care unit. Lancet, 356, 185-189.
63. UK Department of Health. (2002). An Organisation with a Memory - Report of an Expert
Group on Learning from Adverse Events in the NHS. London: UK Department of Health.
34

64. Vincent, C., Taylor-Adams, S., & Stanhope, N. (1998). Framework for analysing risk and
safety in clinical medicine. British Medical Journal, 316 (7138), 1154-1157.
65. Wakefield, M. K. (2001). The relationship between quality and patient safety. In L. Zipperer &
S. Cushman (Eds.), Lessons in Patient Safety (pp. 15-19). Chicago, IL: National Patient Safety
Foundation.
66. Wald, H., & Shojania, K. (2001). Prevention of misidentifications. In D. G. Shojania & B. W.
Duncan & K. M. McDonald & R. M. Wachter (Eds.), Making Health Care Safer: A Critical
Analysis of Patient Safety Practices (pp. 491-503). Washington, DC: Agency for Healthcare
Research and Quality, AHRQ publication 01-E058.
67. Wears, R. L., & Perry, S. J. (2002). Human factors and ergonomics in the emergency depart-
ment. Annals of Emergency Medicine, 40 (2), 206-212.
68. Wilson, J. R. (1995). Ergonomics and participation. In J. R. Wilson & E. N. Corlett (Eds.),
Evaluation of Human Work (Second ed., pp. 1071-1096). London: Taylor & Francis.
69. Wilson, J. R., & Haines, H. M. (1997). Participatory ergonomics. In G. Salvendy (Ed.), Hand-
book of Human Factors and Ergonomics (pp. 490-513). New York: John Wiley & Sons.
70. Wulff, I. A., Westgaard, R. H., & Rasmussen, B. (1999a). Ergonomic criteria in large-scale
engineering design - I - Management by documentation only? Formal organization vs. design-
ers' perceptions. Applied Ergonomics, 30, 191-205.
71. Wulff, I. A., Westgaard, R. H., & Rasmussen, B. (1999b). Ergonomic criteria in large-scale
engineering design - II - Evaluating and applying requirements in the real-world of design. Ap-
plied Ergonomics, 30 (207-221).
72. Zink, K. (2000). Ergonomics in the past and the future: from a German perspective to an inter-
national one. Ergonomics, 43 (7), 920-930.
73. Zink, K. J. (1996). Continuous improvement through employee participation: Some experi-
ences from a long-term study. In O. Brown Jr. & H. W. Hendrick (Eds.), Human Factors in
Organizational Design and Management-V (pp. 155-160). Amsterdam, The Netherlands: El-
sevier.