Now that health care reimbursement is firmly linked to a reduction in hospital-acquired conditions through the enactment of the Affordable Care Act, the entire health care industry has additional incentive to address our patient safety problems aggressively. Although there has been recent progress in patient safety (1), perhaps one reason for the troubling gaps is that all of the variables that contribute to safe and quality care have not been examined together. One often-neglected variable is the physical environment, which shapes every patient experience and all health care delivery, including those episodes of care that result in patient harm.
Other high-risk industries have studied how environmental features can engender human responses that improve safety-related outcomes.(2) Understanding how environmental variables contribute to adverse events in health care represents the focus of a growing body of architects, researchers, and clinicians.(3) A systems approach allows us to evaluate error or adverse events in the context of organizational vulnerabilities. As seen in the Figure, environmental latent conditions undermine system defenses, setting the stage for active failures or establishing error-provoking conditions.(4,5) For example, multiple occupancy patient rooms that are more difficult to clean and have fewer easily accessible handwashing opportunities (bathrooms, sinks, alcohol rubs) may result in increased transmission of health care–associated infections (HAIs) through surface contact.(6,7)
Evidence-based design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.(8) The Center for Health Design, a 501(c)(3) nonprofit organization, is committed to assisting health care organizations achieve this goal through their Pebble Project program (http://www.healthdesign.org/pebble), a research initiative that engages health care organizations during their facility design and construction projects. Team members use research findings to inform decision-making and then conduct additional research to evaluate the effectiveness of implemented design strategies. Below, we discuss some of the key findings from the Pebble partners as they relate to patient safety and summarize the research linking facility design hazards and latent conditions to patient safety outcomes.
Patient Safety Trifecta and Environmental Tools
We have noted three main patient safety areas markedly influenced by the environment: HAIs, medication safety, and falls.
Health Care–Associated Infections
Because HAIs are transmitted through air, water, and contact with contaminated surfaces, the physical environment plays a key role in preventing the spread of infections in health care settings.(9) Evidence shows that single-bed patient rooms with high-efficiency particulate air filters and with negative or positive pressure ventilation are most effective in preventing airborne pathogens.(5) Single-bed patient rooms are also easier to clean and have fewer surfaces that act as reservoirs for pathogens. Additionally, higher sink-to-bed ratios in single-patient rooms is associated with better handwashing compliance—a key factor associated with the spread of HAI.(10) Bronson Methodist Hospital in Kalamazoo, Michigan found that HAI rates among all patient care units declined by 11% (0.89 to 0.80 infections per 1000 patient days) when they moved from an older hospital with mostly semiprivate rooms and shared bathrooms to a new hospital with all private rooms with bathrooms. Moreover, among the six patient care units that changed from semiprivate to private room design, the infection rate declined by 45%.(11) In addition, easy access to alcohol-based rub dispensers in patient rooms has been linked to improved handwashing compliance.(6) One study found that alcohol-rub dispensers located at the foot of the patient bed were better used than those by the sink.(12)
A growing body of research suggests that medication safety is markedly influenced by the physical environmental conditions in areas where medication-related activities occur. These conditions include light levels, sound and noise, workspace design to mitigate interruptions and distractions, and workspace organization.(13) Performance on visual tasks such as dispensing medications improved in an outpatient pharmacy at higher illumination levels.(14) Poor acoustic environments with hard sound reflecting surfaces may contribute to low speech intelligibility, which may also contribute to errors.(15) Acuity-adaptable rooms that enable patients to stay in the same room as their acuity level changes reduce the need for transfers and associated breakdowns in communication that potentially result in error. Hendrich and colleagues (16) found that after a move to an innovative acuity-adaptable Cardiac Comprehensive Critical Care unit at Clarian Methodist Hospital, patient transfers decreased by 90% and medication errors by 70%.
It is widely accepted that the physical environment—including environmental features, such as the placement of doorways, handrails and toilets, flooring type, and the design and location of hazards like furniture—can contribute to patient falls and associated injuries. Because most studies in this area have involved multifaceted-interventions to reduce falls (17-19), the independent impact of any single design strategy remains to be evaluated. Hendrich and colleagues (20) found that most falls occurred when patients attempted to get out of bed unassisted or unobserved. In their study, when patients moved from a centralized unit with semiprivate rooms to decentralized units with single-patient rooms that included a family zone, the number of falls was reduced by two-thirds. Creating space that can accommodate family members (who can help or call for aid) in the patient's room, along with better visibility from the nurses' station represent promising design interventions.
Safe Facility Design Checklist
Over the course of a health care career, all practitioners will be exposed to health care environmental changes that can range from routine maintenance and repair activities to a facility replacement project. Shifting demographics and an aging health care infrastructure will continue to drive historically high health care construction for the foreseeable future.(21) With each facility investment comes an opportunity to harness the environment as a tool to improve both patient and caregiver safety by considering the following questions:
- Have safety goals been identified as a project driver?
- Does the architectural firm have patient safety design expertise?
- Does the design support the desired safety concepts of operation from all perspectives: patients, family and visitors, staff, material movement, equipment, and technology use?
- Are specific resources needed, such as mock-up rooms or virtual tools, to integrate safety culture, process, and environmental feature changes?
- For routine maintenance and repair activities, are there product choices that better support patient safety (e.g., replacing worn ceiling tiles with high-sound absorbing tiles to reduce noise, an error-provoking condition)?
- Have the baseline, preoccupancy safety outcome measures been captured for those variables expected to be impacted by the design?
- Have the postoccupancy evaluations of safety outcomes been included as part of the organization's performance improvement program or in a more formal research study?
The expected growth of health care construction investments over the next 5 years presents a singular opportunity to further our understanding about how the physical environment contributes to safer and more reliable care. Each patient safety improvement plan should consider environmental solutions. As Sir Winston Churchill once remarked, "We shape our buildings, and afterwards our buildings shape us."
Anjali Joseph, PhDDirector of ResearchThe Center for Health Design
Eileen B. Malone, RN, MSN, MSMember, Research CoalitionThe Center for Health Design
1. Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood). 2010;29:165-173. [go to PubMed]
2. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
3. Ulrich RS, Zimring CM, Zhu X, et al. A review of the research literature on evidence-based healthcare design. Health Environ Res Des. 2008;1:61-125. [Available at]
4. Joseph A, Taylor E. Designing for patient safety: developing a patient safety risk assessment. In: Facility Guidelines Institute, ed. 2010 Guidelines for Design and Construction of Health Care Facilities Workshops. Chicago, IL: American Society for Healthcare Engineering; 2010. ISBN: 9780872588592.
5. Joseph A, Rashid M. The architecture of safety: hospital design. Curr Opin Crit Care. 2007;13:714-719. [go to PubMed]
6. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31:283-294. [go to PubMed]
7. Joseph A. The impact of the environment on infections in healthcare facilities. Concord, CA: The Center for Health Design; 2006. [Available at]
8. Evidence-Based Design Accreditation and Certification (EDAC). Concord, CA: The Center for Health Design. [Available at]
9. Bartley JM, Olmsted RN, Haas J. Current views of health care design and construction: practical implications for safer, cleaner environments. Am J Infect Control. 2010;38(5 suppl 1):S1-S12. [go to PubMed]
10. Kaplan LM, McGuckin M. Increasing handwashing compliance with more accessible sinks. Infect Control. 1986;7:408-410. [go to PubMed]
11. Van Enk RA. Modern hospital design for infection control. Healthcare Design. September 1, 2006. [Available at]
12. Somner JEA, Scott KM, Gibb A. What is the optimum location of alcohol-based hand cleanser? Infect Control Hosp Epidemiol. 2007;28:108-109. [go to PubMed]
13. USP-NF. General chapter physical environments that promote safe medication use. Pharmacopeial Forum. 2010;34:1549-1558. [Available at]
14. Buchanan TL, Barker KN, Gibson JT, Jiang BC, Pearson RE. Illumination and errors in dispensing. Am J Hosp Pharm. 1991;48:2137-2145. [go to PubMed]
15. Joseph A, Ulrich R. Sound control for improved outcomes in healthcare settings. Concord, CA: The Center for Health Design; 2007. [Available at]
16. Hendrich A, Fay J, Sorrells A. Effects of acuity-adaptable rooms on flow of patients and delivery of care. Am J Crit Care. 2004;13:35-45. [go to PubMed]
17. Gulwadi GB, Calkins MP. The impact of healthcare environmental design on patient falls. Concord, CA: The Center for Health Design; 2008. [Available at]
18. Choi YS, Lawler E, Boenecke CA, Ponatoski ER, Zimring CM. Developing a multi-systemic fall prevention model, incorporating the physical environment, the care process and technology: a systematic review. J Adv Nurs. 2011;67:2501-2524. [go to PubMed]
19. Malone EB, Dellinger BA. Furniture design features and healthcare outcomes. Concord, CA: The Center for Health Design; 2011. [Available at]
20. Hendrich A. Case study: the impact of acuity adaptable rooms on future designs, bottlenecks and hospital capacity. Paper presented at: Impact Conference on Optimizing the Physical Space for Improved Outcomes, Satisfaction and the Bottom Line; 2003; Atlanta, GA.
21. FMI's Construction Outlook: 1st Quarter 2012 Report. Raleigh, NC: FMI Corporation. [Available at]
22. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998;316:1154-1157. [go to PubMed]
23. Reason J. Human error: models and management. BMJ. 2000;320:768-770. [go to PubMed]
Conceptual model based on Vincent (22) and Reason's (23) work showing the role of the physical environment as a latent condition or barrier/safeguard for patient safety.(4)
(Go to figure citation in the text)
Click to enlarge.