Chapter 28. The Impact of Facility Design on Patient 

Safety 

John Reiling, Ronda G. Hughes, Mike R. Murphy 

Background 

Recent attention in health care has been on the actual architectural design of a hospital 

facility, including its technology and equipment, and its effect on patient safety. To address the 

problems of errors in health care and serious safety issues, fundamental changes of health care 

processes, culture, and the physical environment are necessary and need to be aligned, so that the 

caregivers and the resources that support them are set up for enabling safe care. The facility 

design of the hospital, with its equipment and technology, has not historically considered the 

impact on the quality and safety of patients, yet billions of dollars are and will be invested 

annually in health care facilities. This provides a unique opportunity to use current and emerging 

evidence to improve the physical environment in which nurses and other caregivers work, and 

thus improve both nurse and patient outcomes. 

Human Error and Cognitive Functioning by Design 

Cognitive psychologists have identified the physical environment as having a significant 

impact on safety and human performance.1, 2 Understanding “the interrelationships between 

humans, the tools they use, and the environment in which they live and work”3

 is basic to any 

study of the design a health care facility and its effect on the performance of the nurses and other 

caregivers who interface with the facility and its fixed (e.g., oxygen and suctioning ports on the 

wall of a patient room) and moveable (e.g., a patient bed) equipment and technology. Humans do 

not always behave clumsily and humans do not always err, but they are more likely to do so 

when they work in a badly conceived and designed4 health care setting. 

Organizational/system factors that can potentially create the conditions conducive for errors 

are called latent conditions. According to Reason,1 latent conditions are the inevitable “resident 

pathogens” that “may lie dormant within the system for a long time, only becoming evident 

when they combine with other factors to breach the system’s defenses. Latent conditions can be 

identified and remedied before an adverse event occurs.” Examples of latent conditions are: 

poorly designed facilities, including the location of technology and equipment; confusing 

procedures; training gaps; staff shortages or improper staffing patterns; and poor safety culture. 

A specific example of a latent condition effecting patient safety would be the impact of low 

lighting levels in the medication dispensing areas that are associated with some medication errors 

but not others.5

 These and other conditions occur at what Reason describes as the “blunt end,” 

where administrators, the work environment, and resources determine the processes of care 

delivery. Latent conditions are present in all organizations and can be unintentionally created by 

those who are responsible for designing systems, ensuring adequate staffing, creating and 

enforcing policies, and so on. 

The design of a facility/structure with its fixed and moveable components can have a 

significant impact on human performance, especially on the health and safety of employees, 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

patients, and families.6 In a review of more than 600 articles, researchers found that there was a 

link between the physical environment (i.e., single-bed or multiple-bed patient rooms) and 

patient (e.g., fewer adverse events and better health care quality) and staff outcomes (e.g., 

reduced stress and fatigue and increased effectiveness in delivering care).7

 Efforts to improve 

patient and staff outcomes can target latent conditions for clinicians by using evidence-based 

designs to decrease distractions, standardize locations of equipment and supplies, and ensure 

adequate space for documentation and work areas. The research done by Reason1

 and Leape2

describes the value of practices based on principles designed to compensate for human cognitive 

failings. Thus, when applied to the health care field, human factors research (i.e., an area of 

research that includes human performance, technology design, and human-computer interaction; 

this topic is covered in chapter 5, “A Human Factors Framework,” by Henriksen and colleagues), 

which has emphasized the need for standardization, simplification, and use of protocols and 

checklists, can be used to improve health care outcomes. 

By targeting human factors through facility design and ensuring that latent conditions and 

cognitive failures that lead to adverse events are minimized, patient safety will improve. This 

requires a multifaceted approach, including developing a strong safety culture, redesigning 

systems or facilities with their equipment and technology, focusing on eliminating the conditions 

of cognitive errors, and helping caregivers correct/stop an error before it leads to harm or 

mitigate it if it occurs.1, 2

Factors Influencing the Built Environment 

With human factors in mind, there are several aspects of the built environment that should be 

considered. In a review of the literature by Henriksen and colleagues,8

 the following design 

elements were identified as critical in ensuring patient safety and quality care, based on the six 

quality aims of the Institute of Medicine’s report, Crossing the Quality Chasm: A New Health 

System for the 21st Century:

9

• Patient-centeredness, including 

o using variable-acuity rooms and single-bed rooms 

o ensuring sufficient space to accommodate family members 

o enabling access to health care information 

o having clearly marked signs to navigate the hospital 

• Safety, including 

o applying the design and improving the availability of assistive devices to avert 

patient falls 

o using ventilation and filtration systems to control and prevent the spread of 

infections 

o using surfaces that can be easily decontaminated 

o facilitating hand washing with the availability of sinks and alcohol hand rubs 

o preventing patient and provider injury 

o addressing the sensitivities associated with the interdependencies of care, 

including work spaces and work processes 

• Effectiveness, including 

o use of lighting to enable visual performance 

o use of natural lighting 

o controlling the effects of noise 

2 
Patient Safety & the “Built Environment”

• Efficiency, including 

o standardizing room layout, location of supplies and medical equipment 

o minimizing potential safety threats and improving patient satisfaction by 

minimizing patient transfers with variable-acuity rooms 

• Timeliness, by 

o ensuring rapid response to patient needs 

o eliminating inefficiencies in the processes of care delivery 

o facilitating the clinical work of nurses 

• Equity, by 

o ensuring the size, layout, and functions of the structure meet the diverse care 

needs of patients 

There have been five other significant reviews of the literature relating to the physical 

environment and patient outcomes. Nelson and colleagues10 identified the need to reduce noise 

pollution and enhance factors that can shorten a patient’s length of stay (e.g., natural lighting, 

care in new/remodeled units, and access to music and views of nature); according to their study, 

patients can benefit from the skillful utilization of music and artwork. Ulrich and colleagues7

found research that demonstrated that the design of a hospital can significantly improve patient 

safety by decreasing health care associated infections and medical errors. They also found that 

facility design can have a direct impact on patient and staff satisfaction, a patient’s stress 

experience, and organization performance metrics. Three other reviews found that hospital 

design, particularly when single-bed rooms are employed, can enhance patient safety and create 

environments that are healthier for patients, families, and staff by preventing injury from falls, 

infections, and medical errors; minimizing environmental stressors associated with noise and 

inefficient room and unit layout; and using nature, color, light, and sound to control potential 

stressors.11–13

Nurse staffing levels. Preventable adverse events such as falls and complications have been 

found to be related to both the design of health care facilities and nurse staffing levels. Patient 

falls in acute care settings can result from slippery floors, poor placement of handrails, 

inappropriate door openings, furniture heights,14 and inadequate nurse staffing.15, 16 Infection 

rates have been found to be lower in patients, particularly critically ill patients, when there are 

higher staffing levels.17, 18, 19 High rates of postoperative infections, especially related to wounds 

among patients ages 65 to 70, have been found to be associated with facilities that were 

overcrowded, had few private rooms, lacked individual bathrooms and toilets, had no isolation 

facilities, and had deficient ventilation systems.16 Without effective ventilation systems, efforts 

to avoid ventilator-associated pneumonia—such as patient positioning, oral health, and airway 

management20, 21—have a greater potential of not being as beneficial. Then again, the greater risk 

for health care associated infections may be associated with nurses not implementing evidencebased practices,22 such as aseptic technique or washing hands appropriately18 to prevent 

infections, as well as nurse understaffing;23–26 how much is not known. These are only some of 

the examples that indicate that there are fewer adverse events when appropriate nurse staffing 

levels are met, and operational costs are lower because the rates of adverse events are lowered.27

Thus, adequate staffing must be addressed to enable the benefits of well-designed health care 

facilities. 

Structural obstacles and the nature of work for nurses. Several factors have been 

identified as physically being in the way of the work of nurses. An assessment of the 

organization of nurses in medical and surgical units in hospitals in France found that the work of 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

nurses was dependent upon the spatial configuration of the unit. For purposes of this study, 

nurses’ work areas were divided into four categories: the patients’ rooms, the nurses’ area, the 

corridor, and other specialized areas such as a storage room. Nurses were found to have 

generally followed three paths in their trips: different points of the nurses’ area, trips between the 

patients’ rooms and nurses’ area, and trips between the patients’ rooms. Trips were organized 

according to spatial and functional logic. The majority of the activities performed by nurses were 

found to last less than 2 minutes. On the surgical unit, nurses during one shift were found to 

perform 3,855 trips that lasted approximately 3 minutes and 25 seconds each; this was fewer than 

the 4,521 trips performed by nurses on the medical units, each lasting approximately 3 minutes 

and 9 seconds. The constant movement by nurses varied based on the spatial organization of the 

unit as well as the temporal structure of the tasks. On the surgical unit, nurses were interrupted, 

an average of once every 20 minutes; on the medical unit, nurses were interrupted an average of 

once every 12 minutes.28

One approach to address these obstacles and to better meet patients’ needs is to not have one 

central nursing station. Instead, there would be several decentralized nursing work stations 

throughout the unit with supplies, linens, and equipment areas. Appropriately distributed supplies 

and equipment could reduce fatigue and improve efficiency of nurses29 by minimizing the time 

associated with finding supplies and equipment and moving from one location to another. 

Patients could benefit from more time with nurses and increased surveillance opportunities that 

require nurses to visually monitor patients—a benefit enhanced further by using single-bed 

rooms in hospital design.30

Single-bed and variable-acuity rooms. Debate continues as to whether hospitals should 

have single-bed rooms or semiprivate rooms for patients. Research over the past 10 years has 

compared single to semiprivate rooms and, in so doing, has provided greater insight into cost 

implications, patient satisfaction, and impact on patient care and outcomes. Several reviews of 

the literature found that single-bed rooms were more conducive for infection control and patient 

care,7, 31, 32 were associated with reduced stress and improved outcomes for patients,33 and 

increased privacy and accessibility for patients and families.34 Noise levels and catheter-related 

infections have been found to be lower for critically ill infants in single-bed rooms.35

Comparatively, environmental risk factors for patients in multiple occupancy include lack of 

privacy36 and higher noise levels that can affect their comfort and recovery.37 Environmental 

noise and light as well as patient interruptions can cause sleep disturbance,36 especially in 

intensive care unit patients.38

Patients and families tend to be more satisfied with single-bed rooms. In one study, patient 

satisfaction among low-risk maternity patients was found to be higher with single rooms because 

of having their privacy respected; patients felt they were in a comfortable environment and felt 

that they received more support and education.39 Clinicians have also been found to prefer single 

rooms for maternity patients40 and neonatal intensive care patients.35 

The availability of single-patient rooms has been found to control the spread of infection 

from patients infected with methicillin-resistant Staphylococcus aureus,41–43 gram-negative 

bacteremia in burn patients,44 and respiratory and enteric infections requiring contact isolation in 

pediatric units.45 Single-bed isolation rooms, intended to prevent the spread of infectious agents 

by using pressure differentials to contain them, are effective only if the room is tightly sealed.46

Thus, in terms of controlling infection in isolation rooms and other patient rooms, the greater risk 

may be associated with nurses not implementing evidence-based practices regarding hand 

washing and aseptic technique to prevent infections.18

4 
Patient Safety & the “Built Environment”

The design of a patient room that allows flexibility and can be adapted to meet changing 

acuity and care needs of patients has been found in some institutions to contribute to decreased 

medication errors and falls.47, 48 A well-designed patient room has also been found to be a factor 

in improving care delivery processes for clinicians by providing more private patient 

consultations,36 improving patient and clinician satisfaction,48 decreasing length of stay,29 and 

facilitating continuity of care during a hospital stay.39

Traditionally, the bed charge has been higher for single rooms and the capital investment 

greater. Yet research has found that single rooms and flexible/adaptable rooms for maternity care 

and intermediate and intensive care offered cost savings, particularly because of shorter lengths 

of stay and a decrease in the number of transfers within the hospital.40, 49 Such rooms are more 

likely to be filled47 and can avoid the costs of transfers when the room is acuity adaptable.36

Lessons From Best-Practice Designs 

There are several examples of the impact of evidence-based design in acute care settings; a 

few will be discussed here. Research in the early 1970s found that unit efficiency was 

determined by the design of the unit, not room size or occupancy.50 Research conducted since 

then has continued to emphasize the importance of designs. One study51 began with a systematic 

evaluation of best practices in 19 intensive care units (ICUs), built between 1993 and 2003, that 

received a design award from the Society of Critical Care Medicine, the American Association 

of Critical Care Nurses, and the American Institute of Architects. The reviewer found positive 

characteristics of the ICUs to include single-bed rooms for improved patient care, safety, 

privacy, and comfort; bed locations that provided easy access for clinicians; hand-washing sinks 

and waste disposal in the patient rooms; and use of natural lighting. Negative characteristics 

were found to be renovation projects that posed health and safety hazards during the 

construction; mixed-service units with safety and staffing problems; overall layout—and layout 

of work areas for staff—that lacked a common design solution; and family space that was often 

located outside the unit and provided the family with limited access. 

The Pebble Project, supported by the Center for Health Design and funded by the Robert 

Wood Johnson Foundation, includes several hospitals across the country. As part of this project, 

evidence-based designs are used and empirical evidence is assessed to measure outcomes such as 

safety (visit the Center for Health Design’s Web site at www.healthdesign.org). Findings from 

the Pebble Project are expected to advance the evidence base by increasing our knowledge of 

design features that can ensure a safe healing environment where the best quality of care can be 

provided. The project is intended to have a ripple effect and influence other health care facilities 

nationwide.52

There are several examples of hospitals involved in the Pebble Project, such as Children’s 

Hospital in San Diego, which opened a long-term, convalescent hospital designed to promote the 

care needs for permanently disabled children. The design included out-of-sight wheelchair 

storage in patients’ rooms, private spaces outside the patient rooms for parents to hold their 

children, and an improved ventilation system to decrease respiratory infections. The Methodist 

Hospital in Indianapolis opened a 56-bed cardiovascular critical care unit where patients are 

admitted directly to their rooms from the emergency room, admitting, physicians’ offices, or the 

Lifeline helicopter. Patient rooms are private and patients are in control of the temperature and 

light. Each room also has an interior window that can become opaque to increase privacy. The 

design also enabled nurses to observe patients better, resulting in half as many patient falls, and 

the need for patient transfers has decreased substantially from 200 per month to an average of 20 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

per month. Bronson Methodist Hospital in Michigan opened a new facility with private patient 

rooms and increased patient access to nature (e.g., indoor gardens, natural light, and landscape 

views) and decreased patient stress using of positive distractions such as music, water sounds, 

artwork, and daylight. The Barbara Ann Karmanos Cancer Institute renovated several hospital 

areas to be patient-centered and to provide a more pleasant environment, where patient rooms 

were made larger and an emphasis was placed on lighting and acoustics. In doing so, 

administrators and clinicians have seen a decrease in the use of pain medication and medication 

errors on these units. Thus, by incorporating private rooms into their designs, these four hospitals 

and patients they have served have experienced successful outcomes in their new and renovated 

facilities.53

Research Evidence 

There were 10 original articles that met the inclusion criteria for this review. Four articles 

described investigations with nurses in relation to the work and built environment, five were 

about patient’s perspectives, and two were about specific built environment projects; one study 

investigated both staff and patient perceptions of the built environment.

Nurses’ Perspective 

Four studies assessed hospital nurses’ perspectives on factors associated with the built 

environment using cross-sectional surveys. Two surveys intended to assess the work 

environment and challenges prior to moving forward with specific changes.54, 55 When asked 

about performance obstacles, nurses reported: work environments; distractions from families; 

hectic and crowded work environments; delays in getting medications from the pharmacy; 

amount of time spent teaching families; equipment not being available; patient rooms not well 

stocked; insufficient workspace for completing paperwork; time spent seeking supplies or 

patients’ charts; receiving many phone calls from families; delays in seeing new medical orders; 

and misplaced equipment.54 When asked about what physical changes were problematic in the 

layout of the current unit, including patients’ rooms, pediatric nurses reported that they were not 

satisfied with: the size of residents’ closets, showers, and activity room; the actual size, 

aesthetics, and location of the break room and dining room; the available space for medical 

equipment; the available space for charting; and the outdoor recreation area. Not only did nurses 

share similar concerns with parents, the facility aesthetics and work environment were found to 

be associated with higher satisfaction and better coworker relationships among nurses.55

The other two surveys assessed the perceptions of nurses about single versus multiple bed 

rooms. A very small sample of nurse managers and unit directors (n = 7) in best-practice ICUs 

reported the benefits of single-bed rooms as enhanced patient safety, ensured privacy for 

patients, increased access to patient status information, and more space for family members.56

In the other survey, administrative and nursing staff (n = 77) reported that they favored singleoccupancy rooms because of their flexibility, being more appropriate for patient examination, 

improved quality of patient monitoring and scope of patient surveillance, and improved patient 

comfort level and patient recovery rate. Helpful characteristics of single-occupancy rooms were 

reported as: the more favorable layout of the room, including the availability of extra space in the 

room making arrangement of furniture easier and providing storage for clean and dirty supplies 

in the room; better privacy for patients and more space for family members; and better lighting 

6 
Patient Safety & the “Built Environment”

and temperature control and lower noise levels. A little over half of the respondents believed that 

health care acquired infections were low or very low in single-occupancy rooms, but that there 

was no difference in the number of patient falls or the need for pain-reducing or sleep-inducing 

medications between the two types of rooms. Conversely, helpful characteristics of doubleoccupancy rooms included proximity to the nursing station. However, being able to see patients 

for monitoring purposes was reported as problematic for both single and multiple occupancy 

rooms.57 

Patients’ Perspective and Impact 

Five of the identified studies assessed the perspective of patients who received care in a 

purposefully built environment within hospitals. Two studies used focus groups to assess the 

patients’ perspective, one with hospital inpatients,58 and the other with patients and family 

members in ambulatory care, acute care, and long-term care settings.59 A consistent theme 

among these studies was the preference for an environment that offered quality and comfortable 

personal space, rather than an environment that addressed only medical needs, but none were 

without some aspect that was not favorable. 

Three studies assessed the perspectives of patients and family members in the United States 

and the United Kingdom. Patients and family members in the United States, across various 

settings, reported wanting a health care environment that facilitates connections to clinicians; 

fosters a sense of well-being; and is not dissociated from the world outside the hospital, 

outpatient setting, or long-term care setting.59 Patients in the United Kingdom, hospitalized 

patients in various units (n = 51) reported feeling a loss of independence and control while 

hospitalized, but felt safer and at home when they had the TV close by, and were able to walk 

around. For these patients, the most important factors about the built environment were privacy, 

a homely environment, considerations for disabilities, and being able to see outside and get 

outside.58 Patients in another study in the United Kingdom reported a relationship between the 

environment and internal areas of the hospital and how that made them feel comfortable, able to 

keep a sense of normalcy, and as having a positive affect on their feelings of well-being. Patients 

further reported that they felt that it was important to have good signage, controllable lighting 

and temperature, privacy, reduced noise levels, access to the natural environment, safety and 

security in internal and external areas, internal and external children’s play areas, 

accommodations for visitors, shops and personal services, good 24-7 catering facilities, and good 

landscape designs with seating and garden areas.60

Patient perceptions were assessed after implementation of a built environment in a hospital. 

In one study, there were fewer patients who left against medical advice, aggression levels in 

patients decreased, and levels of benzodiazepine dosing decreased compared to measured 

occurrences before the new unit opened. It is not known if there was any assessment of patients’ 

perceptions.61 Parents (n = 40) in a children’s hospital reported more satisfaction with the 

structure and facility aesthetics, but were not satisfied with space for showers/baths, the amount 

of closet space in the patient room, lack of sufficient private areas to be with their child or for 

outdoor recreation, location of the nurses station, and the low level of natural lighting.55

Acuity-Adaptable Rooms 

One study investigated the impact of an evidence-based design of 56 new acuity-adaptable 

rooms for a combined coronary critical care and step-down unit.62 Researchers found that two 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

different levels of acute care (intensive care and step-down care) could effectively be merged 

together into a single patient room by making the room acuity adaptable to accommodate the 

changing needs of patients. Once in the new single-bed acuity-adaptable unit, researchers found: 

a large reduction in clinician handoffs and transfers; a 70 percent reduction in medication errors; 

a reduction in patient falls; improvements in patient satisfaction; decreases in budgeted nursing 

hours per patient day; and increases in available nursing time for direct care without additional 

cost. Yet, clinicians felt more isolated by the increased size of the unit and with decentralized 

nursing stations; then again, the “isolation” gave nurses greater opportunity for autonomous 

decisionmaking. 

Designed ICU 

The implementation of a new neonatal intensive care unit, designed to have a more efficient 

floor plan, provide space for supportive family-centered care, and to use of natural light, used 

was assessed using multiple methods.63 On this new unit, the majority of nurses were positive 

about the design features. Nurses reported the new unit as enabling efficiency, in part attributable 

to being able to move about the unit at a greater velocity, enabling them to spend more time with 

the infants and less time needed to walk about the unit in the course of their work. The nurses 

also reported that the new unit was more comforting, clean and quieter, and the new lighting was 

thought to have a positive impact on the patients. Additionally, nurses reported that they felt that 

families were utilizing the majority of space designated to them. 

Addressing the Problem: A Case Study 

One new 80-bed community hospital in Wisconsin has been designed to improve patient 

safety through research-based design. Following the report of the Institute of Medicine (IOM), 

To Err Is Human: Designing a Safer Health System,

64 the management and medical staff at St. 

Joseph’s initially believed that adverse events applied to other institutions and not their own. 

When it became apparent that St. Joseph’s, too, had preventable adverse events, top management 

authorized the design of a facility with the equipment and technology to lower or eliminate 

preventable adverse events—a design that could possibly be used as an example by other health 

care organizations that were building new facilities, remodeling, or expanding existing facilities. 

The process began in April 2002, when leadership from SynergyHealth St. Joseph’s Hospital 

met with national leaders representing health care administration, health services research, 

hospital quality improvement and accreditation, hospital architecture, systems engineering, 

medicine, nursing, and pharmacy.65 Using personal experience, human factors principles, health 

care research, and research from other industries, it was agreed that a National Learning Lab, 

would be used to develop recommendations for facility design, define and create a roadmap for 

safety by design, including safe design principles, make recommendations for changes in care 

processes, and enhance safety culture for hospitals through facility design focused on patient 

safety. The specific safety design principles, intended to specifically address both latent 

conditions and active failures, included the following: 

1. Automate where possible. 

2. Design to prevent adverse events (e.g., patient falls, operative/postoperative 

complications and infections, and deaths associated with restraint use). 

3. Design for scalability, adaptability, and flexibility. 

8 
Patient Safety & the “Built Environment”

4. Place accessibility of information in close proximity to the patient. 

5. Improve visibility of patients to staff. 

6. Involve patients in their care. 

7. Minimize fatigue of staff. 

8. Minimize patient transfers/handoffs. 

9. Reduce noise. 

10. Standardize. 

These principles were substantiated by using failure mode and effects analysis throughout the 

design process, involving patients/families, and instituting an organizational culture of safety, 

these principles would enable designs that would support the anticipation, identification, and 

prevention of adverse events.65 

Designing for Nursing Care 

The first step for the National Learning Lab was an educational program about human error 

and its causes associated with latent conditions and active failures. The goal of this education 

was to gain commitment to the need for nurses to be active in the design phase. Then 

representatives of nursing were elected to a facility design committee. Design teams of nurses 

were also formed to assure formal input into the design. Mock-ups were also an important 

feature and prompted more input from the nurses. Many rooms were mocked up, and the 

medical-surgical room was modified multiple times by the involvement of nurses reviewing 

every detail to assure a safe design. Nurses’ involvement in equipment and technology planning 

started immediately with the mock-ups. The interplay between the facility (with its equipment 

and technology) and nurses and patients creates safe or unsafe interactions, and the result is 

affected in large part by the facility design. 

Once the National Learning Lab was over, St. Joseph’s Hospital began the important process 

of implementing the Lab’s recommendations. For St. Joseph’s to implement the National 

Learning Lab’s recommendations, senior leadership knew they needed to involve nurses in the 

facility design process because of nursing’s essential role in caring for patients, and because 

nurses interface with all the systems of a hospital at the “sharp end,” including equipment, 

technology, facilities, and patients—more so then any other care provider in a hospital. Not 

discounting the role of physicians, other clinicians, and health care staff, nurses provide care 24 

hours a day, 7 days a week. As such, nurses providing care are most aware of the best way to 

design a patient room (for example) so the room design minimizes the potential for human error 

and harm to patients. St. Joseph’s organized the design process to maximize the involvement of 

nurses. 

Single-Patient Room 

In many instances, including the need for patient isolation measures, double or multipleoccupancy rooms were viewed as not being conducive to patient safety and quality care. The 

floor plan shown in Figure 1 illustrates how a series of standardized single-patient rooms were 

laid out on both sides of a hallway in St. Joseph’s Hospital. This perspective allows various 

features of the room to be seen in relation to each other. There are two entrances to the room, one 

from the hallway (along the lower edge of the picture), and one from the alcove on the right. In 

that alcove, also entered from the hallway, a desk, computer, and chair are provided for use by 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

staff. The alcove also contains a standardized storage area, so staff can find everything they need 

for the care of the patient adjacent to the patient room. 

The interior of a single-patient room incorporates many of the recommendations relating to 

latent conditions and active failures in the design for safety (see Figure 2). The family area of the 

room is in the right corner of the room, by the window, and includes a couch/pull-out bed, chair, 

desk with Internet connection, and good natural lighting. The treatment area of the room is on the 

left side of the bed, with room all around the bed for patient care. It is intentional, also, that the 

patient is on the nurses’ and other caregivers’ right as that person enters the room from either 

door, so care can be more efficiently provided. Note that the bathroom is at the head of the 

patient’s bed, allowing the patient to get to and from the bathroom without impediments, holding 

onto a rail all the way if necessary. At the head of the bed is the headwall with connections for 

various gases such as oxygen; on the wall to the left of the bed is a pull-down table the caregiver 

can use when it is needed. Although it is not shown in the illustration, there will also be a 

portable cart in each room, with a computer on it. Last but not least, in the lower right-hand 

corner of the room, between the two doorways, easily visible to the patient, there is a sink—an 

ever-present and convenient reminder to nurses, all staff, and visitors to wash their hands. 

Figure 1. Floor Layout of Single-Patient Rooms in St. Joseph’s Hospital 

10 
Patient Safety & the “Built Environment”

Figure 2. Single-Patient Room in St. Joseph’s Hospital 

Applying Knowledge of Active Failures and Latent Conditions to 

Room Design 

The design process for St. Joseph’s Hospital focused on safety, employing broad 

participation, including nurses, physicians, board members, administration, National Learning 

Lab participants, expert consultants, other health systems, health care writers, and design teams. 

The patient room was selected as a good example of how the design plan for the hospital came 

together in one location. To show how the room design was reached, each of the applicable latent 

conditions and active failures will be discussed, to explain how they relate to the plan for a 

single-patient room. 

Noise reduction: Noise interferes with communication, creates distractions, affects cognitive 

performance and concentration, and contributes to stress and fatigue.66 Particularly sensitive are 

mental activities involving working memory.67 Noise can also adversely impact healing, alter 

quality of sleep, and reduce overall perceived patient satisfaction, yet the evidence at present is 

equivocal.68 Since a standardized patient room has a material effect on noise, the bed in each 

single room in St. Joseph’s is in the same location as the next room. In the traditional patient 

room style, called back-to-back, patient beds are on the same wall. Back-to-back plans create 

major transfer noise between rooms, and their use of the same oxygen, compressed room air, and 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

suction intensifies the transfer noise and vibration. In a truly standardized room, this does not 

occur. In addition, the walls between rooms are separated and insulated with airspace, 

minimizing transfer noise. This was designed into the structure early in the building design. In 

addition, vibration noise between floors and within a floor was minimized through design. The 

mechanical, electrical, and plumbing systems were designed to use the optimum materials for 

minimizing noise. This included using vibration isolation/dampening devices wherever vibration 

could be a factor. 

The flooring in the patient room is rubber, second to carpet in sound reduction qualities. The 

reason carpet was not chosen (it was mocked up and tested) is because spills and mishaps needed 

to be cleaned up immediately. Carpet requires housekeeping to bring a carpet cleaner, which 

could take time and also could be embarrassing for the patient. Carpet was chosen, however, for 

the alcoves and hallways, with a low-nap, special carpet for hospital application. Special ceiling 

tiles that absorb noise better than regular ceiling tiles were chosen. Triple glazed windows were 

specified to minimize outside noises. No overhead paging system is used (except for public 

emergencies such as a tornado warning), and nurse call systems use minimal tone with vibrating 

features. As specific equipment and technologies were needed, manufacturers of that piece of 

equipment or technology were contacted and asked how they reduced noise in their products. 

That became one important criterion for selecting which company’s equipment to use. 

Scalability, adaptability, flexibility: Many design and construction concepts can be applied 

to achieve a scalable (e.g., the ability to expand or remodel easily) or adaptable (e.g., the ability 

to adapt space for different or evolving services) health care facility. At St. Joseph’s, all rooms 

have higher-than-normal ceilings to allow changes to be incorporated in the future. Space around 

the bed is sized so procedures (e.g., colonoscopies) could be performed in the room in the future.

Visibility of patients to staff: The importance of being able to see patients is inherent to 

nursing care, a concept that was recognized early by Florence Nightingale, who advocated the 

design of open, long hospital wards to see all patients. The design of units and patient rooms 

should allow caregivers to be in visual proximity to patients; a pod structure can allow close 

proximity and enable quality care by improving efficiency and effectiveness. At St. Joseph’s, 

each alcove door has a glass window with a blind so nurses can work in the alcoves and see the 

patient or check on the patient. The nurse can also check on the patient in the evening without 

opening the door and waking the patient. Each room is wired for cameras for observation. All 

materials, such as medication, linens, IV poles, and a rough-in for icemakers, are delivered to the 

alcove to allow nurses to spend more time with the patient. The chart will initially be in the 

room, but shortly after the new hospital opens, it will be replaced by electronic medical records 

with a workspace so nurses and other caregivers can spend more time with the patient. 

Furthermore, visibility also means lighting to see the patient. Natural light is maximized by large 

windows in every patient room. Light sources after hours are as close to natural light as can be 

achieved cost effectively. Canned lights are located over the patient for assessment. A total of 15 

lights are located in every room, including the bathroom and alcoves. 

Involving patients in their care: The IOM9

 found that many patients have expressed 

frustration with their inability to participate in decisionmaking, to obtain information they need, 

to be heard, and to participate in systems of care that are responsive to their needs. The 

availability of information for patients increases their knowledge regarding their illness and 

treatment options, and being informed gives patients the opportunity to participate in shared 

decisionmaking with clinicians and may help patients better articulate their individual views and 

preferences.69–71 This reflects several dimensions of patient-centered care, including respect for 

12 
Patient Safety & the “Built Environment”

patients’ values, preferences, and expressed needs, as well as providing information, 

communication, and education.72

At St. Joseph’s, the patient room is designed with a treatment section near the door and a 

family section near the window. A couch folds outs into a bed; a desk with an Internet 

connection encourages family members or friends to stay with patients. This is intended to help 

patients to be more active with their care and better able to protect themselves from errors. A 

portable computer on a cart (same one used by staff) is located in each room so patients can have 

appropriate access to their chart. 

Standardization: Standardization has been documented as an important human factorsbased design strategy 4, 64 that can help lessen the number of errors. Standardization reduces 

reliance on short-term memory and allows those unfamiliar with a specific process or design to 

use it safely.64 With a focus on improving the human-system interface by designing better 

processes and systems, standardization of patient rooms, treatment areas, equipment, and 

procedures can substantially reduce errors.64

There were many design elements that incorporated standardization as a physical attribute.

The patient rooms in St. Joseph’s may be the first patient rooms in the country to be 

standardized. The headwalls are standardized throughout the facility; a seven-drawer 

configuration was designed into every patient room or alcove to provide consistency of supply 

locations and to simplify the restocking of those supplies. This provides staff with a known 

constant, regardless of where they may be caring for a patient throughout the facility due to 

floating, a patient resuscitation, or some other emergent situation. The electronic medical record, 

use of bar-coding, computerized provider order entry, and other technologies will be 

standardized eventually, assisting in the development of standardized protocols and order sets. 

The facility materials distribution and routine nurse functions can also be standardized to match 

the facility. 

Equipment is not fully standardized yet, but that is the goal, since fully standardized 

equipment provides the highest level of safety. The complexity and variety in equipment vendors 

and models is immense, and this complexity creates more errors. This weakness—the lack of 

equipment standardization—was pointed out continually in using failure and effects mode 

analysis. So St. Joseph’s is evolving toward equipment standardization. The hospital was able to 

purchase limited new patient monitoring equipment, and took care to assure that new and 

existing equipment were from the same vendor to give the user a similar feel and functionality, 

regardless of which equipment they were using. The hospital will continue to utilize this process 

to guarantee long-term equipment standardization within the facility. 

Automation where possible: The IOM identified health information technology solutions as 

a necessary component to improving patient safety.9

 As discussed in the chapter on health 

information technology, technologies such as electronic medical records can improve 

communication and information dissemination between providers. 

At St. Joseph’s, electronic medical records, bar-coding, physician order entry, a pneumatic 

tube system, two computers in every room (one in the alcove and one on a cart in the room), a 

sophisticated nurse call system, new patient beds, and patients lifts for every room are examples 

of automation. These applications are intended to allow caregivers to give care more efficiently 

and rely less on short-term memory. Many design features and technology applications have 

affected multiple latent conditions. This was one of the important criteria used at the matrix 

exercise to determine which design features to include. Technology applications were deemed to 

be a critical part of allowing St. Joseph’s to design for safety. 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Immediate accessibility of information, close to the point of service: In order to provide 

patients with the most accurate diagnosis and treatment possible, clinicians need to have 

complete, real-time information about the patient, care needs, and treatment options. 

Technologies such as the Internet, electronic medical records, and clinical decision-support 

systems can accomplish this. At St. Joseph’s, electronic medical records were seen as the most 

useful way of making information accessible quickly at the point of service. When the hospital 

opened, the patient chart was 100 percent paper based. In traditional hospital environments, the 

patient chart changes location without regard to patient activities. Early mornings, a physician 

may come around and take the chart to a quiet dictation area to write notes and orders. The chart 

is often left there until another care provider requires the chart. Or, the chart may be left with the 

unit secretary to input/transcribe orders. 

A transitional plan was developed to meet this guiding principle: When the hospital opened, 

a mandate was incorporated into the physician and staff orientation that the chart on the 

medical/surgical unit never leaves the alcove unless the patient leaves. This was surprisingly 

effective and compliance was unusually high. When an order is written, the physician uses a 

wall-mounted button labeled “New Order” or “Stat Order” to alert the unit clerk. The unit clerk 

then transcribes the order and does any necessary computer order entry in the alcove. The chart 

never leaves the alcove. Anecdotally, the physicians find this process useful to them. They can 

make rounds more efficiently, since they never have to look for a chart to write their notes or 

orders. They never have to “batch” their rounding and then look for all of the charts to document. 

Verbal orders are also reduced. For obvious reasons, this process will cease to be relevant when 

the electronic medical record is implemented. 

Minimizing fatigue: Fatigue has been identified as a contributing factor to human error.73, 74

While the effects of fatigue on patient safety is not known, fatigue has been found to have a 

negative impact on alertness, mood, and psychomotor and cognitive performance, which can 

have an impact on patient safety.74–76 Some of the effects of long work hours and increasing 

workload can be mitigated by minimizing the distances staff must travel between patient rooms, 

and by using health information technology at the bedside to reduce reliance on short-term 

memory and thought processes. Other considerations in the design of St. Joseph’s to minimize 

fatigue are carpeting and rubber flooring, a chair in the alcove, single rooms, keeping all 

materials in the alcove so nurses have to take fewer steps, less reliance on short-term memory, 

less noise, natural light, and strong lighting sources. 

Minimizing patient transfers/handoffs: Transferring patients from one unit, room, or floor 

to another puts both the patient and staff at risk of harm, and it is disruptive to both patients and 

clinicians. Often these transfers involve handoffs, which, as described in another chapter in this 

book, also place the patient and clinician at risk for errors. Minimizing patient transfers and 

handoffs has design implications. Private single rooms with appropriate space around the beds, 

lifts, and other safety mechanisms allow more procedures to be performed in the room. This is 

similar to the model in obstetrics with Labor Delivery Recovery Post-Partum (LDRP) rooms, 

where the mother delivers the child and the child can remain with the mother in the same room 

for the entire stay. Another example is the physical therapy gym located on the med-surg unit—

the patient never leaves the unit to obtain therapy, and their nurse is always in close proximity 

should a change in patient condition occur. Electronic medical records are another important 

tool. Bar-coding helps with continually and accurately identifying the patient. 

14 
Patient Safety & the “Built Environment”

Addressing the Root Causes of Precarious Events

The approaches used by St. Joseph’s to address root causes for other types of at risk areas are 

described as follows: 

Operative/postoperative complications and infections: Among the design features that 

will contribute to the reduction in operative/postoperative complications and infections are 

private rooms; a sink at the entrance to the medical/surgical patient rooms, which you must pass 

going in either door (to encourage hand washing); internal window blinds (to reduce 

accumulation of dust); a housewide air filtration system that includes central HEPA filters; 

ultraviolet lights in all clinical areas; airflow systems in which clean air passes the patient and is 

recycled and filtered again; and a radiant heat panel above or below every patient window to 

eliminate condensation. These are all features that minimize infection. Air supply and return 

grates that need cleaning have been upgraded to stainless steel so cleaning is more effective. 

However, the most important design element is the location of the sink, since lack of hand 

washing is the number one reason for hospital-acquired infections. 

Inpatient suicides: Data from the Joint Commission indicate that out of the approximately 

1,500 to 1,800 suicides that occur annually in hospitals, about 50 percent of those occur in 

medical/surgical units. The two most common methods are jumping and hanging. In a 

medical/surgical room, there are many things patients can use to hang themselves, such as 

bathroom curtain rods, showerheads, television brackets, or lights. Thus, St. Joseph’s decided to 

use breakaway shower curtain rods and minimize other hanging risks by choosing lights and 

brackets that met the design needs of the room but would be less likely to be used for a suicide 

attempt. To minimize jumping, windows cannot be opened, and they are triple-paned, making 

them much harder to break through. If a suicide-risk patient is identified, that patient is 

transferred to the mental health unit, but increased visibility in all patient rooms helps staff keep 

a closer watch, which helps minimize the risk of suicides. 

Death of patients in restraints, patient falls: St. Joseph’s, like most hospitals, has 

minimized restraints. The new beds ordered for the hospital have eliminated many of the risks of 

deaths due to restraints. With less and less restraints, however, the risk of falls rises. Most 

patients fall at night or while walking with a nurse or other caregiver. Design elements that help 

reduce falls include fixed night lights in every room, beds that drop down to sixteen inches above 

the floor, locating the bathroom at the head of the bed with railings to the stool and shower, and 

utilizing bathroom lights that automatically turn on when anyone enters the bathroom. Besides 

the above-mentioned strategies, a bed-exit system is being explored using infrared technology. If 

a patient is identified as he is trying to get out of bed, then lights could turn on, an emergency 

call to the pager could occur, or a voice could ask the patient to wait for a caregiver. Such a 

system is in design at St. Joseph’s. 

Correct tube—correct connector—correct hole placement events, oxygen cylinder 

hazards: All connectors are a different size for different gases and color-coded. Storage and 

identification of portable gases employ the same identification program. All gases are in 

standardized locations to further minimize the risk of a gas-connecting error. 

Wrong-site surgery: Operating room suites were standardized, using proper lighting and 

cable access to digital images and photographs of the surgery site. 

Medication and transfusion-related adverse events: Bar-coding, unit doses at point of 

service, electronic medical records, and physician order entry are critical elements for medication 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

error reduction. Private rooms with alcoves that include medical records allow nurses to 

concentrate on one patient and document those efforts, before moving on to the next patient. 

Bringing It All Together at St. Joseph’s Community Hospital 

The use of failure mode and effects analysis, patient focus groups, mock-ups with employee 

evaluation, and checklist safety design principles (latent conditions and active failures) helped St. 

Joseph’s create the safest room they could envision. The patient room evolved over months of 

design. Over 27 different designs or refinements were made on the patient room. This room is 

not the only way a patient room can be designed for safety, but it is believed to be a good way, 

and it exhibits efficient, thoughtful features that meet National Learning Lab expectations. 

The 2002 National Learning Lab had a powerful effect on St. Joseph’s and is beginning to 

influence hospital facility development nationally. St. Joseph’s Hospital implemented the 

recommendations of the Learning Lab, designing around latent conditions and active failures, 

and enhancing or creating a safety culture through facility design with its technology and 

equipment. The importance of nursing leadership in the whole process cannot be overstated. 

Without the commitment, knowledge, and perseverance of the nursing leadership, along with the 

chief executive officer, board, medical staff, architects, and the rest of the design teams, a safe 

design would not have occurred. 

The effort of St. Joseph’s is just the tip of the iceberg of the potential for improving safety of 

patients in hospitals as a result of facility development. The impact of the National Learning Lab 

recommendations on processes also offers an immense opportunity to improve the safety of 

patients in hospitals. The work of St. Joseph’s should serve as a model for those health care 

leaders who share the vision that facilities, including equipment and technology, focused on 

safety will improve the health and well-being of the patients whom they serve. 

The building of the new hospital was completed in 2005, and investigators are currently 

evaluating the impact of their designs on the frequency of adverse events and patient outcomes. 

Using innovative architectural and design features to enhance patient safety together with 

institutionalizing a nonpunitive safety culture can potentially have a greater impact than design 

features alone. Over the past few years, the National Learning Lab changed St. Joseph’s Hospital 

and has begun to influence hospitals and health care throughout the country. 

Leaders and clinicians at St. Joseph’s found that the project, with its many safety 

enhancements, resulted in capital expenditures under budget—an important consideration in the 

business case. The National Learning Lab’s process of identifying and addressing latent 

conditions was correlated with the Toyota Lean Principles. Standardization, visibility, 

continuous flow, value stream, minimizing handoffs/transfers will be created as a result of a 

safely designed facility. This should lead to less human error and potential harm and more 

efficient operations (process). Yet, one of the major difficulties of translating this efficiency and 

better outcomes into improved net income is the basic misalignment of financial incentives. Both 

the fee-for-service and the DRG (diagnosis-related group) introduce perverse incentives. 

Hospital revenues can actually be reduced as a result of improved safety, and savings can accrue 

to the insurance companies and not the institutions creating the improvements. Although there is 

some evidence of changes to improve these misaligned incentives, more dramatic changes are 

needed to encourage safe process redesign. 

16 
Patient Safety & the “Built Environment”

Practice Implications 

The evidence base is growing in support of evidence-based design for renovations and new 

building. The new field of evidence-based design has emerged at a time when there is a health 

care construction boom.77 There are many factors in the workplace that impact care delivery and 

work satisfaction, and they should be incorporated into designs. Based on the Gurses and 

Carayon study,54 care processes will need to be modified to address inefficiencies caused by 

distractions (e.g., by family members), overly busy working conditions, delays in getting access 

to required resources (e.g., medications, patient medical records, supplies, and medical 

equipment), delays in seeing new medical orders, and misplaced equipment.54

Nurses need to be involved and have an active role in evaluating, planning, and testing the 

layout of patient units and patient rooms to ensure a healing and comfortable environment for 

both patients and clinicians. Lessons learned should be shared with others to enable 

improvements across the country, not just on one facility. Current laws and regulations will need 

to be modified to support new hospital standards and building codes.10 As single-bed patient 

rooms are now considered the minimum standard for maternity/postpartum and intensive care 

units in general hospitals,78 nurses will need to be involved in planning for transitions and 

assessing environmental and structural features that will improve the quality of care afforded 

patient. 

Research Implications 

The impact of the built environment will most likely be magnified by concurrent efforts to 

change organization culture and functionality as well as processes of care delivery, but future 

research would need to so demonstrate. Since the majority of the research on the impact of the 

built environment has been conducted in specific units in hospital settings, it will be important to 

investigate whether similar effects can be realized in general medical-surgical units and 

outpatient settings, including clinics and offices. 

In a 2004 report commissioned by the Agency for Healthcare Research and Quality, The 

Hospital Built Environment: What Role Might Funders of Health Services Research Play,

10 the 

following gaps in the literature were identified: What are the effects of the built environment on 

the quality of communication and information sharing between clinicians, patients, and families? 

What is the relationship between environmental factors and the working conditions for 

clinicians? What are the best mechanisms and designs for facilitating effective hand washing? 

What is the effect of elements in the built environment that reduce staff fatigue, distractions, and 

stress? And what is the role of the built environment in decreasing infection rates across patient 

types? Nurses can have a critical role in addressing these and other research gaps. In this 

relatively new and exciting area of research in health care, nurses need to and should be actively 

involved throughout the research and quality improvement processes involving the design of the 

work environment space. 

Conclusions 

In the next few years, hospital leaders will be involved in new hospital construction projects 

to meet the changing marketplace demands associated with the growing demand of an aging 

population. Many clinicians, architects, and hospital administrators believe that the hospital built 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

environment can benefit the satisfaction of health care providers as well as patient satisfaction 

and outcomes. There is some evidence that the built environment may influence patient and 

family perceptions of the quality of and satisfaction with care received during a hospitalization. 

There is also some evidence that nurse satisfaction with the built environment was related to 

general well-being and job satisfaction, two factors that are critical because of their impact on 

patient care. 

The evidence-base is emerging to support the business case that designing for safety and 

quality can improve patient outcomes and safety, promote healing, increase patient satisfaction, 

and reduce costs. It is thought that the cost of building or remodeling projects based on design 

evidence conducive to patient safety can result in organizational savings over time, without 

adversely impacting revenues.8 Investigators with the Center for Health Design have been 

assessing hospitals involved in the Pebbles Project, and have found that the financial incentive 

for investing in evidence-based design using therapeutic design elements such as single-bed 

rooms and decentralized nursing stations added close to $12 million in costs to hospital 

reconstruction—but those costs would be recouped within one year of being operational.79 

Those building new or remodeling current facilities should consider beginning with 

transitioning to a culture of safety, then using a safe design as a matter of focusing on 

maximizing the safety features without expending additional capital resources. While relatively 

new, evidence is growing in objective assessments of the impact of built environments, 

particularly around the issue of infection control. Some safety features will cost more than 

traditionally designed facilities (e.g., HEPA filters and ultraviolet lighting to improve air quality) 

while other safety features will cost less than a traditionally designed facility, most notably 

standardization. In all, most of the safety features of a built environment involve a reordering of 

functions in most “traditionally” designed facilities, minimally affecting capital costs, to improve 

the quality of care and patient outcomes. 

Search Strategy 

PubMed® was searched to locate studies and related literature on the built environment. Most 

of the articles identified in the literature search were primarily descriptive. Search terms included 

“built,” “environment,” “hospital design and construction,” “interior design and furnishings,” 

“patients’ rooms,” and “health care.” Excluded from the review were articles published before 

1999, non-English language articles, expert opinions, case reports, and letters. Three hundred 

abstracts were obtained. To be considered evidence in this review, the research had to involve 

nurses or patients in clinical settings, reported findings related to patient safety, and not be 

specific only to health information technology. 

Author Affiliations 

John Reiling, Ph.D., M.H.A., M.B.A., president and CEO, Synergy Health/St. Joseph’s 

Hospital. E-mail: jreiling@snyergyhealth.org. 

Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for 

Healthcare Research and Quality. E-mail: Ronda.Hughes@ahrq.hhs.gov. 

Mike R. Murphy, R.N., B.S.N., M.B.A., vice president administration and CNO, Synergy 

Health/St. Joseph’s Hospital. E-mail: mmurphy@stjosephswb.com. 

18 
Patient Safety & the “Built Environment”

References 

1. Reason J. Making the risks of organizational 

accidents. Aldershot, England: Ashgate Publishing; 

1997. 

2. Leape LL. Error in medicine. JAMA 1994; 272:1851-

7. 

3. Weinger MB. Incorporating human factors into the 

design of medical devices. MAMA 1998; 280:1484. 

4. Norman DA. The psychology of everyday things. 

USA: Basic Books; 1988. 

5. Buchannan TI, Barker KN, Gibson JT, et al. 

Illumination and errors in dispensing. Am J Hosp 

Pharm 1991; 48:2137-45. 

6. American Institute of Architects, Academy of 

Architecture for Health, The Facility Guidelines 

Institute (with assistance from the U.S. Department 

of Health and Human Services). Guidelines for 

design and construction of hospital and health care 

facilities. Washington, DC: AIA Press; 2001. 

7. Ulrich R, Quan X, Zimring C, et al. The role of the 

physical environment in the hospital of the 21st 

century: a once-in-a-lifetime opportunity. Report to 

The Center for Health Design, for the designing for 

the 21st century hospital project, 2004. Accessed at 

www.healthdesign.org/research/reports/physical_envi

ron.php. 

8. Henriksen K, Isaacson S, Sadler BL, et al. The role of 

the physical environment in crossing the quality 

chasm. Jt Comm J Qual Patient Safety 2007; 33(11 

Suppl):68-80. 

9. Institute of Medicine. Crossing the quality chasm: a 

new health system for the 21st century. Washington, 

DC: National Academy Press; 2001. 

10. Nelson C, West T, Goodman C. The hospital built 

environment: what role might funders of health 

services research play? Contract no: 290-04-0011. 

Rockville, MD: Agency for Healthcare Research and 

Quality; 2005 Aug. AHRQ Publication No. 06-0106-

EF. 

11. Joseph A. The role of the physical and social 

environment in promoting health, safety, and 

effectiveness in the healthcare workplace. Concord, 

CA: Center for Health Design; 2006. Accessed at 

www.healthdesign.org/research/reports/ 

workplace.php. 

12. Joseph A. The impact of light on outcomes in 

healthcare settings. Concord, CA: Center for Health 

Design; 2006. Accessed at www.healthdesign.org/ 

research/reports/longtermcare.php. 

13. Joseph A, Ulrich R. Sound control for improved 

outcomes in healthcare settings. Concord, CA: Center 

for Health Design; 2007. 

14. Brandis S. A collaborative occupational therapy and 

nursing approach to falls prevention in hospital 

inpatients. J Qual Clin Pract 1999; 19(4):215-20. 

15. Tutuarima JA, de Haan RJ, Limburg M. Number of 

nursing staff and falls: a case-control study on falls 

by stroke patients in acute-care settings. J Adv Nurs 

1993; 18(7):1101-5. 

16. Andersen BM, Rasch M. Hospital-acquired infections 

in Norwegian long-term-care institutions. A threeyear survey of hospital-acquired infections and 

antibiotic treatment in nursing/residential homes, 

including 4500 residents in Oslo. J Hosp Infect 

2000;46(4):288-96. 

17. Hugonnet S, Chevrolet JC, Pittet D. The effect of 

workload on infection risk in critically ill patients. 

Crit Care Med 2007;35:76-81. 

18. Archibald LK, Manning ML, Bell LM, et al. Patient 

density, nurse-to-patient ratio and nosocomial 

infection risk in a pediatric cardiac intensive care 

unit. Pediatr Infect Dis J 1997;16:1045-8. 

19. Stegenga J, Bell E, Matlow A. The role of nurse 

understaffing in nosocomial viral gastrointestinal 

infections on a general pediatrics ward. Infect 

Control Hosp Epidemiol 2002;23:133-6. 

20. Grap MJ, Munro CL. Preventing ventilatorassociated pneumonia: evidence-based care. Crit 

Care Nurs Clin North Am. 2004 Sep;16:349-58, viii. 

21. Lindgren VA, Ames NJ. Caring for patients on 

mechanical ventilation: what research indicates is 

best practice. Am J Nurs 2005;105(5):50-60; quiz 61. 

22. Carson CL, Tyner T, Saunders S, et al. Nurses’ 

implementation of guidelines for ventilatorassociated pneumonia from the Centers for Disease 

Control and Prevention. Am J Crit Care 

2007;16(1):28-36; discussion 37; quiz 38. 

23. Dancer SJ, Coyne M, Speekenbrink A, et al. MRSA 

acquisition in an intensive care unit. Am J Infect 

Control 2006;34:10-7. 

19 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

24. Bittner MJ, Rich EC, Turner PD, et al. Limited 

impact of sustained simple feedback based on soap 

and paper towel consumtion of the frequency of hand 

washing in a adult intensive care unit. Infect Control 

Hosp Epidemiol 2002;23(3):120-6. 

25. Bittner MJ, Rick EC. Surveillance of handwashing 

episodes in adult intensive-care units by measuring 

an index of soap and paper towel consumption. Clin 

Perform Qual Health Care 1998;6(4):179-82. 

26. Arenas MD, Sanchez-Paya J, Barril G, et al. A 

multicentric survey of the practice of hand hygiene in 

haemodialysis units; factors affecting compliance. 

Nephrol Dial Transplant 2005;20:1164-71. Epub 

2005 Mar 15. 

27. Cho SH, Ketefian S, Barkauskas VH, et al. The 

effects of nurse staffing on adverse events, morbidity, 

mortality and medical costs. Nurs Res 2003; 

52(2):71-9. 

28. Gadbois C, Bourgeois P, Goeh-Akue-Gad MM, et al. 

Hospital design and the temporal and spatial 

organization of nursing activity. Work Stress 

1992;6(3):277-91. 

29. Brown KK, Gallant D. Impacting patient outcomes 

through design: acuity adaptable care/universal room 

design. Crit Care Nurs Q 2006;29(4):326-41. 

30. Institute of Medicine. Keeping patients safe: 

transforming the work environment of nurses. 

Washing, DC: National Academy Press; 2004. 

31. Bobrow M, Thomas J. Multibed verses single-bed 

rooms. In Kobus R, Skaggs RL, Bobrow M, et al., 

eds. Building type basics for healthcare facilities 

New York: John Wiley & Sons; 2000.p.145-57. 

32. Muto CA, Jernigan JA, Ostorowski BE, et al. SHEA 

guideline for preventing nosocomical transmissiln of 

multidrug-resistent strains of Staphylococcus aureus 

and Enterococcus. Infect Control Epidemiol 

2003;24:362-86. 

33. Knutt E. Healthcare design. Build for the future. 

Health Serv J 2005; 115(5940):35-7. 

34. White RD. Individual rooms in the NICU—an 

evolving concept. J Perinatol 2003; 23 Suppl 1:S22-

4. 

35. Walsh WF, McCullough KL, White RD. Room for 

improvement: nurses’ perceptions of providing care 

in a single room newborn intensive care setting. Adv 

Neonatal Care 2006;6(5):261-70. 

36. Ulrich RS. Creating a healing environment with 

evidence-based design. Paper presented at the 

American Institute of Architects Academy of 

Architecture for Health Virtual seminar-Healing 

Environments. October 10, 2003. 

37. Bayo MV, Garcia AM, Garcia A. Noise levels in a 

urban hospital and workers’ subjective responses. 

Arch Environ Health 1995; 50(3):247-51. 

38. Meyer TJ, Eveloff SE, Bauer MS, et al. Adverse 

environmental conditions in the respirator and 

medical ICU settings. Chest 1994; 105(4):1211-6. 

39. Janssen PA, Klein MC, Harris SJ, et al. Single room 

maternity care and client satisfaction. Birth 

2000;27(4):235-43. 

40. Harris SJ, Farren MD, Janssen PA, et al. Single room 

maternity care: perinatal outcomes, economic costs 

and physician preferences. J Obstet Gynaecol Can 

2004; 26(7):633-40. 

41. Bracco D, Dubois MJ, Bauali R, et al. Single rooms 

may help to prevent nosocomial bloodstream 

infection and cross-transmission of methicillinresitant Staphylococcus aureus in intensive care units. 

Intensive Care Med 2007; 33(5):836-40. 

42. Rigenour GA, Wong ES, Call MA, et al. Duration of 

colonization with methicillin-resistant 

Staphylococcus aureus among patients in the 

intensive care unit: implications for intervention. 

Infect Control Hosp Epidemiol 2006; 27:271-8. 

43. Herr CE, Heckrodt TH, Hofmann FA, et al. 

Additional costs for preventing the spread of 

methicillin-resistant Staphylococcus aureus and a 

strategy for reducing these costs on a surgical ward. 

Infect Control Hosp Epidemiol 2003; 24:673-8. 

44. McManus AT, Mason AD Jr., McManus WF, et al. A 

decade of reduced gram-negative infections and 

mortality associated with improved isolation of 

burned patients. Arch Surg 1994; 129:1306-9. 

45. Langley JM, Hanakowski M, Bortolussi R. Demand 

for isolation beds in a pediatric hospital. Am J Infect 

Control 1994; 22(4):207-11. 

46. Saravia SA, Raynor PC, Streifel AJ. A performance 

assessment of airborne infection isolation rooms. Am 

J Infect Control 2007;35(5):324-31. 

47. Bobrow M, Thomas J. Hospitals’ prosperity should 

be by design. Mod Healthc 2000; 24(47):54. 

48. Gallant D, Lanning K. Streamlining patient care 

processes through flexible room and equipment 

design. Crit Care Nurs Q 2001;24(3):59-76. 

20 
Patient Safety & the “Built Environment”

49. Besserman E, Teres D, Logan A, et al. Use of 

flexible intermediate and intensive care to reduce 

multiple transfers of patients. Am J Crit Care 

1999;8:170-9. 

50. Thompson JD, Goldin G. A Yale traffic index. In 

Thompson JD, Goldin G, eds. The hospital: a social 

and architectural history. New Haven, CT: Yale 

University Press; 1975. p. 282-95. 

51. Rashid M. A decade of adult intensive care unit 

design: a study of the physical design features of the 

best-practice examples. Crit Care Nurs 2006; 

29(4):282-311. 

52. Sadler B. Design to compete in managed healthcare. 

Facilities Design and Management 2001 March:38-

41. 

53. Bilchik GS. A better place to heal. Health Forum J 

2002;45(4):10-5. 

54. Gurses AP, Carayon P. Performance obstacles of 

intensive care nurses. Nurs Res 2007; 56(3):185-94. 

55. Varni JW, Burwinkle TM, Dickinson P, et al. 

Evaluation of the built environment at a children’s 

convalescent hospital: development of the pediatric 

quality of life inventoryTM parent and staff 

satisfaction measures for pediatric health care 

facilities. J Dev Behav Pediatr 2004; 25(1):10-20. 

56. Rashid M. Developing scales to evaluate staff 

perception of the effects of the physical environment 

on patient comfort, patient safety, patient privacy, 

family integration with patient care, and staff 

working conditions in adult intensive care units: a 

pilot study. Crit Care Nurs Q 2007;30(3):271-83. 

57. Chaudhury H, Mahmood A, Valente M. Nurses’ 

perception of single-occupancy versus 

multioccupancy rooms in acute care environments: 

an exploratory comparative assessment. Appl Nurs 

Res 2006;19:118-25. 

58. Douglas CH, Douglas MR. Patient-friendly hospital 

environments: exploring the patients’ perspective. 

Health Expect 2004;7:61-73. 

59. Fowler E, MacRae S, Stern A, et al. The built 

environment as a component of quality care: 

understanding and including the patient’s 

perspective. Jt Comm J Qual Improv 1999;25(7):352-

62. 

60. Douglas CH, Douglas MR. Patient-centered 

improvements in health-care built environments: 

perspectives and design indicators. Health Expect 

2005; 8(3):264-76. 

61. Feeney L, Kavanagh A, Kelly BD, et al. Moving to a 

purpose built acute psychiatric unit on a general 

hospital site – does the new environment produce 

change for the better? Ir Med J 2007;100(3):391-3. 

62. Hendrich AL, Fay J, Sorrells AK. Effects of acuityadaptable rooms on flow of patients and delivery of 

care. Am J Crit Care 2004; 13(1):35-45. 

63. Shepley MM. Predesign and postoccupancy analysis 

of staff behavior in a neonatal intensive care unit. 

Child Health Care 2002;31(3):237-53. 

64. Institute of Medicine. To err is human: building a 

safer health system. Washington, DC: National 

Academy Press; 1999. 

65. Reiling J. Safe design of healthcare facilities. Qual 

Saf Health Care 2006; 15(Suppl 1):i34-i40. 

66. Belojevic G, Jakovljevic B, Slepcevic V. Noise and 

mental performance: personality attributes and noise 

sensitivity. Noise Health 2003;6(21):77-89. 

67. Stansfeld SA, Matheson MP. Noise pollution: nonauditory effects on health. Br Med Bull 2003;68:243-

57. 

68. van de Glind I, de Roode S, Goossensen A. Do 

patients in hospitals benefit from single rooms? A 

literature review. Health Policy 2007; 84(2-3):153-

161. 

69. Safran DG, Karp M, Coltin K, et al. Measuring 

patients’ experiences with individual primary care 

physicians. Results of a statewide demonstration 

project. J Gen Intern Med 2006;21(1):13-21. 

70. Deyo RA. Tell it like it is. J Gen Intern Med 

2000;15:752. 

71. Wensing M, Grol R. What can patients do to improve 

health care? Health Expect 1998;2:82-92. 

72. Gerteis M, Edgman-Levitan S, Daley J. Through the 

patient’s eyes. understanding and promoting patientcentered care. San Francisco, CA: Jossey-Bass; 1993. 

73. Ternov S. The human side of mistakes. In Spath PL, 

ed. Error reduction in health care. San Francisco: 

Jossey Bass; 2000. p. 97-138. 

74. Jha AK, Duncan BW, Bates DW. Fatigue, sleepiness, 

and medical errors. In Shojania KG, Duncan BW, 

McDonald KM, et al., eds. Making health care safer: 

a critical analysis of patient safety practices. 

Evidence report/technology assessment, No. 43. 

Rockville, MD: Agency for Healthcare Research and 

Quality; 2002. chapter 40. Available at 

www.ahrq.gov/clinic/ptsafety/chap40.htm. 

21 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

75. Gaba DM, Howard SK. Fatigue among clinicians and 

the safety of patients. N Engl J Med 2002;347:1249-

54. 

78. American Institute of Architects (AIA). Guidelines 

for design and construction of health care facilities. 

Washington, DC: American Academy of 

Architecture; 2006. 

76. Hales BM, Pronovost PJ. The checklist – a tool for 

error management and performance improvement. J 

Crit Care 2006;21(3):231-5. 

79. Zimring C, Ulrich R. The role of the physical 

environment in the hospital of the 21st century: a 

once-in-a-lifetime opportunity. Concord, CA: The 

77. Hamilton DK. The four levels of evidence-based Center for Health Design; 2004. 

practice. J Healthc Des 2003 November;18-26; 

22 
Evidence Table 

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Chaudhury 200657 Single-occupancy rooms in acute 

care 

Crosssectional study 

Survey of nurses about patient care, management, and infection control issues (Level 4). 

77 administrative and staff nurses in 3 hospitals in Washington and 1 in Oregon 

None Nurses favor sing

because of their appropriate for pof patient monitocomfort level, imprate, and scope o57 percent believacquired infectiosingle-occupancy There was no difpatient falls, need sleep-inducing mtwo types of roomHelpful characterrooms were layoof space in the rofurniture; privacymembers; storagsupplies; and the bathroom, door, temperature contlevels. Helpful characterrooms were proxvisibility of patienpurposes; and thbathroom, door, 

23
24

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Douglas 200560

Built environment Patient-centered 

care 

Crosssectional study 

Multiple methods, including 50 personal interviews, autophotographic study with 35 patients, noviceexpert cohort of patients and clinicians, and a survey of past patients (Level 4). 

None Patients viewed t

internal areas of them feel comforsense of normalceffect on their feeNovices and expfollowing importacontrollable lightiprivacy; reduced natural environminternal and exteexternal childrenaccommodations personal servicesfacilities; and gooseating and gardPatients reported (e.g., feel of the eand at home, havbeing able to waPatients felt a loscontrol.

Douglas 200458

Built environment Crosssectional 

study 

Face-to-face interviews with hospital inpatients (Level 4). 

21 patients in surgery, medicine, care of the elderly, and maternity in 1 hospital in the UK 

None Patients reported 

(e.g., feel of the eand at home, havbeing able to waPatients interviewindependence anMost important faenvironment werenvironment, conbeing able to see outside. 

Feeney 200761

Built environment Crosssectional 

study 

Assess the impact of a new, purpose-built acute unit on patients’ behaviors and care needs (Level 4). 

1 psychiatric unit in a hospital in Ireland 

Implementation of a purposebuilt acute psychiatric unit in a hospital in Ireland 

After the new unfewer patients thadvice, aggressiodecreased, and ldosing decrease
25

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Fowler 199959

Built environment Crosssectional 

study 

Conducted 9 focus groups with patients (Level 4). 

Patients in ambulatory, acute care, and long-term care settings 

None Patients and fam

environment that staff and caregivsense of well-beiconnection to the 

Gurses 200754 Effects of physical environment Cross- sectional 

study 

Survey of nurses in intensive care units (ICUs) (Level 4). 

272 nurses in 17 ICUs in 7 hospitals in Wisconsin 

None Reported perform

noisy work envirofamilies, hectic aenvironments, defrom pharmacy, afamilies, equipmepatient rooms noworkspace for cospent seeking sureceiving many pdelay in seeing nmisplaced equipm

Hendrich 200462 Acuity-adaptable rooms Pretest, post-test Implementation of new acuity-adaptable 

rooms (Level 3). 

A coronary critical care unit and its step-down medical unit at 1 hospital in Indiana 

Evidence-based design of 56 new acuityadaptable rooms for the combined coronary critical care and stepdown unit. 

After the move, tin clinician handopercent reduction reduction in patiepatient satisfactionursing hours peavailable nursing without additiona

Rashid 200756 Effects of physical environment Cross- sectional 

study 

Development of a survey instrument about underlying effects of environmental features on staff perception of patient comfort, patient safety, patient privacy, family integration, and working conditions (Level 4). 

Nurse managers/directors in 7 adult ICUs built between 1993 and 2003 

None Respondents rep

rooms enabled pprivacy of patientinformation and simportant; and flelocations and adewere important. 
26

Source Safety Issue 

Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Shepley 200263

Built environment Pretest, 

post-test design 

A multi-method approach using behavioral mapping; interviews; questionnaires; and calibrated measures of walking, noise, and temperature (Level 3). 

21 nurses were observed, 10 completed the questionnaire, and 8 nurses were interviewed in a neonatal ICU in 1 hospital. 

Implementation of a new neonatal ICU, where the new design focused on the development of a more efficient floor plan, the provision of space for supportive family-centered care, and the use of natural light 

On the new unit, spend most of thcare, followed by passive baby carwas spent taking new unit than on Those respondinperceived the neclean but less seFamily-centered supportive of babthough its ratings supportiveness oThe unit was rateefficient and the to have a positive Those who were families were utildesignated to thewas efficient, lighnoise levels were 

Varni 200455 Built environment Crosssectional 

study 

Development of a measurement instrument about the built environment (Level 4). 

Parents and staff in a children’s convalescent hospital 

None Parent satisfactio

facility aesthetics higher satisfactioStaff satisfaction and work environhigher satisfactiorelationships.