An illustration showing the many parts that make up the healthcare system, including healthcare staff, diagnostics, medication and different services like emergency care.

The investigator's toolkit: SEIPS

By Deinniol Owens and Dr Helen Vosper

17 January 2024

Continuing our series of blogs that look at the range of investigation methods we use, Deinniol Owens and Dr Helen Vosper highlight how SEIPS can be the investigator’s ‘swiss army knife’ when planning and undertaking patient safety investigations.

Deinniol Owens, Deputy Director of Investigations.
Deinniol Owens, Deputy Director of Investigations at HSSIB.

Introducing SEIPS

The systems engineering initiative for patient safety (SEIPS) is a framework to help us understand outcomes within complex socio-technical systems, like healthcare. SEIPS has developed over a number of academic papers and offers a range of tools that can help an investigator to understand why things happen.

Many staff involved in investigating healthcare are now aware of SEIPS via the NHS England Patient Safety Incident Response Framework (PSIRF). PSIRF encourages the use of SEIPS when investigating patient safety incidents. Resources are available on the NHS England website to help staff when using SEIPS.

Helen Vosper
Dr Helen Vosper, Senior Investigation Science Educator at HSSIB.

Our education programme includes training and advice on how to use SEIPS. It’s as a key part of this course: A systems approach to investigating and learning from patient safety incidents. We’re also developing new courses to help healthcare staff to further understand how to use SEIPS in practice.

HSSIB investigations use SEIPS as a framework to help make sure we are always ‘thinking in systems’ when undertaking various parts of our work. This has included using SEIPS, or elements of it, to help us with:

  • investigation planning
  • evidence collection
  • adding the patient perspective
  • analysis
  • report writing
  • debrief.

Investigation planning

We use SEIPS to help plan our evidence collection with patients and families, healthcare staff, organisations and in preparing for observation visits. This helps us to think across the system and consider what types of evidence we may need to explore an issue from a systems perspective.

Evidence collection

We use SEIPS while we are collecting evidence, from recording key notes from observations or conversations with staff under SEIPS in the moment, to referring back to SEIPS to check-in on whether we have a balanced spread of evidence to allow us to think across the whole work system. This helps us to make sure we are not missing important information that we may then need to find out later.

Adding the patient perspective

We can use SEIPS to ‘flip perspective’ during our investigations. Investigations can often focus on how care is delivered from the perspective of the organisation or staff involved. By using SEIPS to also consider incidents and interactions from a patient perspective, this helps us to improve safety by better exploring how patients interact and experience care.


We can use SEIPS to explore different levels of the work system. From a ‘general SEIPS’ that helps us get initial insight into a process or problem, to drilling down deeper into individual tasks or processes in more detail.

We have found it is harder to use SEIPS to explore ‘up and out’ from a local system. This is where we can use other methods alongside SEIPS that can offer a more structured view of the external environment or interactions outside of the local work system, such as Accimpas, FRAM, or STAMP-CAST.

We have also been able to use SEIPS as a basis to help us with thematic reviews of investigation reports, to help us identify common factors impacting on safety that we can then go on to explore in more detail. Such as our national learning report into never events.

How you can use SEIPS depends on the issue you are investigating and the time and resource you have available. However, it is helpful to make time upfront to think about how you are going to use SEIPS, or any associated tools, to make sure this is clear to the investigation team.

Report writing

Writing a report that represents the themes we have identified from our SEIPS analysis helps to bring all our evidence together to show the complexity of healthcare work and strengthen the systems-based focus of our reports.

We’ve also found that using SEIPS in a graphic can help tell a visual story about a complex work system and increase engagement with our reports by key staff who can help make changes to improve safety, such as in our placement of nasogastric tubes report.

An example SEIPS diagram showing different work-system factors (Person, Organisation, Task, Physical Environment, Tools/Technology/Equipment, and External Environment) that impacted on the placement of a nasogastric tube.
SEIPS graphic from our 'Placement of nasogastric tubes' patient safety investigation report.


We’ve used SEIPS as a foundation to help us to develop a model for debriefing on our investigations, to help us focus on how our systems and processes work and to help drive improvement. This helps us focus on factors that positively and negatively impacted our investigation and improve our processes across:

  • the investigation team
  • our technology
  • our tools
  • our key investigation tasks
  • our working environment
  • our organisational factors
  • external factors.

Actions for healthcare incident investigators

Understanding SEIPS, and the tools that accompany it, is a great way for investigators to adopt an approach that can help us to start to ‘think in systems’ at different stages of an investigation.

We need to remember that SEIPS is not just about putting things in work system ‘buckets’. The key to how it works is when it lets us see how different factors interact across work systems and how people and organisations make adaptations. We can also use other methods and tools for incident investigation to supplement SEIPS if we want to focus more closely in or ‘up and out’ on the system.

Our experience has taught us not to be afraid to embrace SEIPS and try out new ways of working to further improve how we investigate and make sure that we are always grounding our investigations in a systems-based approach.

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Carayon, P., Schoofs Hundt, A., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: the SEIPS model. Quality & safety in health care, 15 Suppl 1(Suppl 1), i50–i58. (Work system design for patient safety: the SEIPS model - PMC (

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. (SEIPS 2.0: A human factors framework for studying and improving the work of healthcare professionals and patients - PMC (

Carayon, P., Wooldridge, A., Hoonakker, P., Hundt, A. S., & Kelly, M. M. (2020). SEIPS 3.0: Human-centered design of the patient journey for patient safety. Applied ergonomics, 84, 103033. (SEIPS 3.0: Human-Centered Design of the Patient Journey for Patient Safety (

Holden, R. J., & Carayon, P. (2021). SEIPS 101 and seven simple SEIPS tools. BMJ quality & safety, 30(11), 901–910. (SEIPS 101 and seven simple SEIPS tools - PMC (

NHS England. (2023). SEIPS quick reference guide. Available online: B1465-SEIPS-quick-reference-and-work-system-explorer-v1-FINAL-1.pdf ( AND SEIPS template: B1465-SEIPS-Blank-template-v1-FINAL.pptx (

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