Understanding Design Vulnerabilities in the Physical Environment Relating to Patient Fall Patterns in a Psychiatric Hospital: Seven Years of Sentinel Events.

BACKGROUND: The influence of the physical environment on patient falls has not been fully explored in psychiatric units, despite this patient population's vulnerability and the critical role of the physical environment in patient safety. AIMS: The research objective is to describe the spatial and temporal pattern of falls occurrences and their location in relation to the levels of safety continuum model. METHOD: This article presents an exploratory case study design. Seven years of retrospective data on patient falls, yielding 818 sentinel events, in an 81-bed psychiatric hospital in the United States were collected and analyzed. Data focused on extrinsic factors for falls, emphasizing the physical environment. Through a content analysis of the sentinel event narratives, recorded by the hospital staff, this study explored patient falls related to location and elements of the physical environment. RESULTS: The analysis revealed that 15% of recorded falls were attributed to some aspect of or element within the physical environment. The most typical locations of falls were patient rooms (39%), patient bathrooms (22%), and dayrooms (20%). Also, the results identified patterns of environmental factors that appeared linked to increasing patients' susceptibility to falls. Risk factors included poor nighttime lighting, flooring surfaces that were uneven, and spaces that inadvertently limited visual access and supervision. CONCLUSIONS: The physical environment plays an often-unexamined role in fall events and specific locations. These results are deserving of further research on design strategies and applications to reduce patient falls in psychiatric hospital settings.

The Impact of Sensory Stimuli on Healthcare Workers and Outcomes in Trauma Rooms: A Focus Group Study.

OBJECTIVE: This study investigated issues related to noise, lighting, and temperature in trauma rooms that impact patient care and staff performance. BACKGROUND: Uncontrolled sensory stimuli can hinder healthcare delivery quality in trauma rooms. High noise and temperature levels can increase staff stress and discomfort as well as patient discomfort. Conversely, proper lighting can decrease staff stress levels and reduce burnout. Sensory overload in trauma rooms is a crucial concern, but no studies have been conducted on this issue. METHOD: Using a convenience sampling method, 65 trauma team members (e.g., surgeons, physicians, nurses) from six Level I trauma centers in the United States were recruited to participate in 20 focus groups. Focus groups were semi-structured and 1 hr long. RESULTS: Staff covered issues related to communications and disruption from noise sources (e.g., equipment, conversations). Having control over lighting allows staff to change light intensity and facilitate their work during the resuscitation. A well-maintained temperature can provide patient comfort or reduce risk of hypothermia, given that patients can lose body heat rapidly due to loss of blood. CONCLUSION: Excessive sensory stimuli can result in disrupted communication, fatigue, and stress, making staff susceptible to errors. Staffs' control over environmental conditions may lead to a more efficient, comfortable, and safer environment. Technology should be reliable and flexible to facilitate this.

The influence of physical environment on health care-associated infections: A literature review.

BACKGROUND: Health care-associated infections (HAIs) are a common issue in health care settings, caused by environmental microorganisms, leading to health risks and financial strain. Despite efforts to reduce HAIs, the role of the physical environment in reducing HAIs is not fully understood. This literature review aimed to identify physical environment variables contributing to HAIs. METHODS: A literature search was conducted in scientific databases between 2016 and 2022 using keywords associated with infections and physical environment variables. After screening retrieved articles for eligibility, the articles were analyzed for relevant environmental and infection variables. RESULTS: Out of 145, 27 articles were identified. The findings were grouped into 8 categories, including layout design, surfaces, behavior, lighting, Internet of Things, materials, airflow, and air quality, with sub-themes in each group. CONCLUSIONS: The physical environment in health care facilities plays a crucial role in reducing and preventing the spread of HAIs. Proper design and construction of health care buildings, including ventilation and air conditioning systems, help prevent infection spread between functional areas. Antimicrobial materials, cleaning and disinfection protocols, and personal hygiene practices, such as hand hygiene, are key factors in infection control. The positioning of hand hygiene stations is also essential to improve compliance among health care professionals.

Drive-Through Urgent Care Centers: Could They Be the Future of Healthcare Facilities?

OBJECTIVE: This study assessed the perception of people toward drive-through healthcare services, their willingness to use them, and the scope of services they would like to receive in a post-pandemic world. BACKGROUND: The abrupt spread of COVID-19 urged healthcare facilities to adopt new infection-control measures. Drive-through testing facilities were implemented as one of the measures to minimize physical contact between healthcare workers and test-takers. Many studies describe drive-through models' merits, but people's opinions about them as a permanent attachment to healthcare facilities are unclear. METHODS: An online survey was distributed through snowball sampling. The survey solicited feedback from adults who lived in the United States. The survey consisted of Likert-type and multiple-choice questions and was completed by176 eligible participants. RESULTS: The use of drive-through pharmacies increased after the spread of COVID-19. Most people agreed drive-through healthcare services could be more convenient and safer to use. People prefer to have their vitals checked, and vaccinations received in a drive-through because of the improved infection-control matters and increased comfort; however, they are neutral about the level of privacy they have and the hygiene of drive-through healthcare settings. CONCLUSIONS: This study shows permanent drive-throughs offering medical services benefit people in times of crisis for the perceived infection control purposes and the improved convenience. A drive-through model can redefine the waiting experience and serve as a new safe triage system in urgent care centers. Drive-through urgent care centers can be adopted as a hybrid of telemedicine and in-person visits.

Understanding "Work as Done": Using a Structured Video-Based Observational Method to Understand and Model the Role of the Physical Environment in Complex Clinical Work Systems.

OBJECTIVE: To describe the planning, development, and implementation of a structured video-based observational method that can be used to systematically examine and model the role of the physical environment within healthcare systems. BACKGROUND: Direct observation methods are often used in healthcare to study complex healthcare systems. However, these observations often occur in real time, which predisposes the collected data to shortcomings such as time lags in recording of activities, overlooking events, or limiting the scope of information than can be collected. Video observation approaches eliminate many of these challenges and provide opportunities for researchers to understand and model the role of the physical environment. METHODS: An approach to developing and implementing a structured video-based observational method to study and model complex health systems is presented. RESULTS: A structured observational approach can be highly effective for collecting multiple layers of data necessary for understanding interactions between the physical environment and other systems components in healthcare settings. The proposed video-based observation method is effective in settings that have clearly defined environmental boundaries, limited number of people, are complex and fast-paced such as the OR, ED trauma rooms, and ICU rooms. CONCLUSIONS: Video-based observation is an effective complement to the traditional observational method for in-depth study of the built environment in health systems, enabling researchers to employ quantitative approaches to data collection and analysis, in addition to qualitative interpretations.

Technology integration in complex healthcare environments: A systematic literature review.

To support safety and efficient care, effective integration of technology into the timepressured, high-risk healthcare environments is critical. This systematic literature review aimed to highlight the impact of technology on the physical environment as well as the facilitators for and barriers to technology integration into complex healthcare settings, including operating rooms and trauma rooms. PsycINFO, Web of Science, and PubMed databases were utilized, along with a hand search. PRISMA and MMAT guidelines were used for reporting and quality appraisal. Out of 1,001 articles, 20 were eligible. Identified categories included hybrid and integrated environments, technological ambiance, and information technologies. Technology integration has implications for direct patient care, efficiency, throughput, patient safety, teamwork, communication, and the perception of care. The facilitators for and barriers to technology integration included layout design, equipment positioning, and decluttering. The physical environment can improve the impact of technology on factors such as patient safety and efficiency.

Research in the Healthcare Design Practice: Design Practitioners' Perspective.

OBJECTIVE: This study explores design practitioners' level of knowledge about research, their attitude toward research integration into the design practice, and the barriers to its application in the design process. BACKGROUND: Design practitioners tend to heavily rely on previous design experience and precedents rather than utilization and application of research. Research can facilitate the evaluation and creation of innovative design solutions. Integrating research has been a challenge for the design industry. METHODOLOGY: The study utilized an online survey to solicit feedback from architects and interior designers in the healthcare sector through a snowball sampling approach. The survey comprised closed-ended and open-ended questions categorized into three distinct sections, each focusing on one of the study objectives. A total of 115 participants completed the questionnaire. RESULTS: Practitioners tend to integrate research into the early design phases and programming. It is recognized as a tool for design enhancement by 62%, while 7% considered it to be a hindrance to their creativity. Primary data collection methods include collaboration with colleagues and user groups rather than journals and trade magazines. Cost, time, and lack of expertise are the top three hurdles in applying research in practice. CONCLUSIONS: Practitioners have a positive attitude toward research, perceive it as an impactful design enhancement tool, and use it to promote their credibility. Lack of research expertise hinders the use and conduct of research. According to design practitioners, research is costly and time-consuming and impedes their ability to fulfill clients' goals and the project timeline.

The relationship between sensory stimuli and the physical environment in complex healthcare settings: A systematic literature review.

OBJECTIVES: This systematic review presented the current status of literature on the outcomes resulted from sensory stimuli in critical care environments as well as the environmental interventions that can improve or impede the impact of such sensory stimuli. METHODS: Articles found through a systematic search of PsycINFO, Web of Science, and PubMed databases, in combination with a hand search, were reviewed for eligibility by two independent coders. Reporting and quality appraisals were based on PRISMA and MMAT guidelines. RESULTS: Out of 1118 articles found, and only 30 were eligible. Final articles were comprised of issues related to noise, lighting, and temperature. Identified sensory stimuli resulted in psychological and physiological outcomes among both patients and staff. Examples include impacts on stress, delirium, sleep disturbances, poor performance and communication. The environmental factors that influence sensory stimuli included layout, room size, artificial lighting, presence of windows and acoustical interventions. CONCLUSION: Literature on the impact of sensory stimuli on staff is scarce compared to patients. Studies on environmental interventions are inadequate and lack structure. The physical environment can impact the patient and staff outcome resulting from noise, lighting, and temperature. When applied strategically, sensory stimuli can result in positive outcomes among patients and staff.

Efficiency and Teamwork in Emergency Departments: Perception of Staff on Design Interventions.

OBJECTIVES: The goal of this study is twofold: (1) identifying design strategies that enhance efficiency and support teamwork in emergency departments (EDs) and (2) identifying design features that contribute to the spread of COVID-19, based on staff perception. BACKGROUND: Due to increasing ED visits annually, an efficient work environment has become one of the main concerns in designing EDs. According to the literature, an efficient work environment and teamwork improve healthcare outcomes and positively impact staff satisfaction. During the COVID-19 pandemic, EDs faced various changes such as workflow and space usage. Few studies explored staff perceptions about the influence of design features on efficiency, teamwork, and the COVID-19 spread. METHOD: An online survey with 14 open- and closed-ended questions was distributed among ED staff members to collect data about unit design features that impact efficiency, teamwork, and the COVID-19 spread. RESULTS: The central nursing station was one of the preferred configurations that increased efficiency and teamwork in EDs. Decentralizing disposal rooms in small-size EDs and decentralizing the medication room in large-size EDs with more than 65 exam rooms can decrease staff walking steps. Flexibility to expand treatment spaces on demand, one-way track circulation path, and changing the air pressure in COVID-19 treatment areas were some of the staff suggestions for future EDs. CONCLUSION: The findings of this study contribute to the body of knowledge that EDs' physical environments can impact efficiency and teamwork among staff and, consequently, healthcare outcomes. Compartmentalization of the ED layout can reduce the spread of COVID-19.

The Role of the Physical Environment in Shaping Interruptions and Disruptions in Complex Health Care Settings: A Scoping Review.

Interruptions and disruptions in complex healthcare environments, such as trauma rooms, can lead to compromised workflow and safety issues due to the physical environment's characteristics. This scoping review investigated the impact of the physical environment on interruptions and disruptions and the associated outcomes in complex environments, as they relate to the components of the Systems Engineering Initiative for Patient Safety. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used to conduct the scoping review. CINAHL, Web of Science, and PubMed databases were searched. After removing duplicates and eligibility screening, quality assessment was conducted using the Mixed Methods Appraisal Tool (MMAT). Of 1,158 articles found, 20 were selected. Poor layout configurations, tripping hazards, and technology integration were common examples. More research must be conducted to unveil the impact of the physical environment on interruptions and disruptions.

Using Virtual Reality to Compare Design Alternatives Using Subjective and Objective Evaluation Methods.

OBJECTIVE: This study sought to develop a method that supports a more evidence-based approach to evaluating multiple design options in virtual reality (VR), combining subjective insights gathered using traditional approaches and objective feedback gathered using the VR platform. Additionally, this study sought to understand how objective data garnered from the VR platform could be used to compliment traditional evaluation strategies. BACKGROUND: VR can be a viable research platform for supporting evidence-based design practices. Prior studies have predominately utilized experiential user feedback. While able to provide valuable subjective insights, these approaches are less effective in making objective comparisons between multiple designs alternatives. METHOD: A repeated measures study was conducted with nursing faculty. User feedback was captured through surveys, interviews, and the VR platform. RESULTS: The survey, interview, and the objective VR data converged in terms of identifying the highest performing design option. Survey data showed that Room 2 performed best in terms of perceived physical access to supplies, unobstructed movement, and availability of space to accommodate additional equipment. VR data showed that participants in Room 2 had significantly higher visibility to both patient and care partners throughout their simulated interaction. CONCLUSION: Simulation-based evaluations in VR that use a combination of users' subjective insights and objective data obtained from VR can be an effective tool for helping designers evaluate multiple design options. The use of scenario-based simulations provided a structured and clinically relevant approach to comparing three preoperative rooms, supporting a more robust assessment of users' physical response to a simulated healthcare environment.

Implications of a Decentralized Postpartum Unit Design and Clinical Operations.

OBJECTIVES: This postoccupancy study sought to understand whether a decentralized unit design supported a postpartum care delivery model by evaluating nurses' efficiency, staff perception, acoustical conditions, and patient satisfaction. BACKGROUND: Today, standardization and decentralization design concepts are being applied to all types of inpatient unit. There have been many studies that investigated how these concepts influence care delivery on medical-surgical units, but no study has evaluated a postpartum unit. METHODS: This study utilized a mixed-method approach that involved unobtrusive shadowing (roughly 25 hr) and surveying (n = 19) of nursing staff, physical acoustic readings (eight, 24-hr readings), and comparison of patient satisfaction pre- and postmove. RESULTS: On average, nurses spent roughly 36.90% of their time at charting stations. Nurses were observed mostly using the central charting station located at the entry of the unit and adjacent to the well-baby nursery rather than the five decentralized chart stations. This was due to nurses operating with old workflow habits, not fully integrating electronic medical records, and needing to be near the nursery and other nurses. Nurses were satisfied with their ability to interact and their proximity to supplies, patients, and team members while in the central charting station. Additionally, patient satisfaction significantly increased postmove, particularly with the overall hospital's quietness and cleanliness. CONCLUSION: This study highlights the importance of aligning administrative operations of the unit with the design intent. Although standardization and decentralization design concepts aimed to improve nurses' workflow, misalignment with the operations may not deliver the most optimal outcomes.

Comparing the Effectiveness of Four Different Design Media in Communicating Desired Performance Outcomes With Clinical End Users.

OBJECTIVE: The purpose of this study was to compare the effectiveness of four different design communication media in helping clinical end users understand spatial and functional information and in supporting their ability to provide design feedback. BACKGROUND: It is critical to involve clinical end users early in the design process to test design solutions and ensure the design of a new healthcare facility supports their ability to deliver high-quality care. Traditional architectural design communication media such as floor plans and perspectives can be challenging for clinical design team members to understand. Physical and virtual mock-ups are becoming more popular as design communication media. However, nominal evidence exists comparing the effectiveness of different design media in supporting clinical end-user engagement and contribution during the design process. METHOD: An exploratory, qualitative study was conducted with clinical end users to evaluate the effectiveness of four different media commonly used in design communication. RESULTS: Traditional architectural representations convey limited useful information to clinical end users, impacting the amount and type of feedback they can provide. More immersive media, such as physical and virtual mock-ups, support an increasingly holistic understanding of proposed design solutions, inciting more design solutions that range from the inclusion and exclusion of design features to location, position, and functionality of those features. CONCLUSIONS: When used in combination, each media can contribute to eliciting clinical end-user feedback at varying scales. The overall preference and higher effectiveness in eliciting design feedback from clinical end users highlights the importance of physical mock-up in communicating healthcare design solutions.

Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room.

BACKGROUND: Studies in operating rooms (OR) show that minor disruptions tend to group together to result in serious adverse events such as surgical errors. Understanding the characteristics of these minor flow disruptions (FD) that impact major events is important in order to proactively design safer systems OBJECTIVE: The purpose of this study is to use a systems approach to investigate the aetiology of minor and major FDs in ORs in terms of the people involved, tasks performed and OR traffic, as well as the location of FDs and other environmental characteristics of the OR that may contribute to these disruptions. METHODS: Using direct observation and classification of FDs via video recordings of 28 surgical procedures, this study modelled the impact of a range of system factors-location of minor FDs, roles of staff members involved in FDs, type of staff activities as well as OR traffic-related factors-on major FDs in the OR. RESULTS: The rate of major FDs increases as the rate of minor FDs increases, especially in the context of equipment-related FDs, and specific physical locations in the OR. Circulating nurse-related minor FDs and minor FDs that took place in the transitional zone 2, near the foot of the surgical table, were also related to an increase in the rate of major FDs. This study also found that more major and minor FDs took place in the anaesthesia zone compared with all other OR zones. Layout-related disruptions comprised more than half of all observed FDs. CONCLUSION: Room design and layout issues may create barriers to task performance, potentially contributing to the escalation of FDs in the OR.

Using a systems approach to evaluate a circulating nurse's work patterns and workflow disruptions.

The physical environment affects how work is done in operating rooms (OR). The circulating nurse (CN), in particular, requires access to and interacts with materials, equipment, and technology more than other OR team members. Naturalistic study of CN behavior is therefore valuable in assessing how OR space and physical configuration influences work patterns and disruptions. This study evaluated the CNs' work patterns and flow disruptions (FD) by analyzing 25 surgeries across three different ORs. The OR layouts were divided into transitional and functional zones, and the work of CNs was categorized into patient, equipment, material, and information tasks. The results reveal that information tasks involve less movement than other types of work, while across all ORs, CNs were more likely to be involved in layout and environmental hazard FDs when involved in patient, material, or equipment-related tasks compared to information tasks. Different CN work patterns and flow disruptions between ORs suggest a link between OR layout and a CN's work. Future studies should examine how specific layout elements influence outcomes.

Setting the Stage: A Comparative Analysis of an Onstage/Offstage and a Linear Clinic Modules.

OBJECTIVE: The purpose of this study was to understand how two different ambulatory design modules-traditional and onstage/offstage-impact operational efficiency, patient throughput, staff collaboration, and patient privacy. BACKGROUND: Delivery of healthcare is greatly shifting to ambulatory settings because of rapid advancement of medicine and technology, resulting in more day procedures and follow-up care occurring outside of hospitals. It is anticipated that outpatient services will grow roughly 15-23% within the next 10 years (Sg2, 2014). Nonetheless, there is limited research that evaluates how the built environment impacts care delivery and patient outcomes. METHOD: This is a cross-sectional, comparative study consisted of a mixed-method approach that included shadowing clinic staff and observing and surveying patients. The linear module had shared corridors and publicly exposed workstations, whereas the onstage/offstage module separates patient/visitors from staff with dedicated patient corridors leading to exam rooms (onstage) and enclosed staff work cores (offstage). Roughly 35 hr of clinic staff shadowing and 55 hr of patient observations occurred. A total of 269 questionnaires were completed by patients/visitors. RESULTS: The results demonstrate that the onstage/offstage module significantly improved staff workflow, reduced travel distances, increased communication in private areas, and significantly reduced patient throughput and wait times. However, patients' perception of privacy did not change among the two modules. CONCLUSION: Compared to the linear module, this study provides evidence that the onstage/offstage module could have helped to optimize operational efficiencies, staff workflow, and patient throughput.

Safety, Performance, and Satisfaction Outcomes in the Operating Room: A Literature Review.

OBJECTIVE: This review of empirical literature focuses on the design of operating rooms (ORs) by investigating the physical environmental features of ORs associated with patient and staff outcomes. BACKGROUND: Many ORs built more than 30 years ago remain operational today. However, most are inadequately designed to handle the equipment, processes, and people that a contemporary OR needs to accommodate. However, the evidence base for designing ORs has been sorely lacking, and little guidance exists on how OR design can improve safety and performance outcomes. METHOD: A literature search was conducted using PubMed and the university's linked databases. The inclusion criteria included peer-reviewed journal articles that reported some aspect of the physical environment of ORs along with outcomes. The study included empirical studies as well as nonempirical best practice papers. RESULTS: This literature review uncovered 211 articles. The main themes that emerged include OR design-related factors, ventilation, temperature and humidity, acoustical environment, lighting, and materials. Some environmental threats to patient safety in the OR include frequent door openings, clutter, poor air quality, surface contamination, and noise. Further, staff performance and satisfaction were impacted by factors such as the OR layout and equipment and furniture ergonomics. CONCLUSION: This literature review provides an overview of the research organized into design-focused topic areas to support decision-making by architects and designers. This article highlights gaps in the research and identifies areas where best practice and design assumptions need to be evaluated using rigorous design research.

Using an integrative mock-up simulation approach for evidence-based evaluation of operating room design prototypes.

This paper describes the process and tools developed as part of a multidisciplinary collaborative simulation-based approach for iterative design and evaluation of operating room (OR) prototypes. Full-scale physical mock-ups of healthcare spaces offer an opportunity to actively communicate with and to engage multidisciplinary stakeholders in the design process. While mock-ups are increasingly being used in healthcare facility design projects, they are rarely evaluated in a manner to support active user feedback and engagement. Researchers and architecture students worked closely with clinicians and architects to develop OR design prototypes and engaged clinical end-users in simulated scenarios. An evaluation toolkit was developed to compare design prototypes. The mock-up evaluation helped the team make key decisions about room size, location of OR table, intra-room zoning, and doors location. Structured simulation based mock-up evaluations conducted in the design process can help stakeholders visualize their future workspace and provide active feedback.

The Impact of Operating Room Layout on Circulating Nurse's Work Patterns and Flow Disruptions: A Behavioral Mapping Study.

AIM: To assess how the adjacencies of functionally different areas within operating rooms (ORs) can influence the circulating nurse's (CN) workflow patterns and disruptions. BACKGROUND: The CN plays a significant role in promoting patient safety during surgical procedures by observing, monitoring, and managing potential threats at and around the surgical field. Their work requires constant movement to different parts of the OR to support team members. The layout of the OR and crowded and cluttered environment might impact the CN's workflow and cause disruptions during the surgery. METHOD: A convenience sample of 25 surgeries were video recorded and thematically coded for CN's activities, locations, and flow disruptions. The OR layout was categorized into transitional zones and functional zones (workstations, supply zones, support zones, and sterile areas around the surgical table). CN's activities were classified into patient-, equipment-, material-, and information-related activities. Flow disruptions included those related to environmental hazards and layout. RESULTS: The CN traveled through multiple zones during 91% of the activities. The CN's workstation acted as a main hub from which the CN made frequent trips to both sides of the surgical table, the foot of the OR table, supply zones, and support zones. Transitional zones accounted for 58.3% of all flow disruption that the CN was involved in whereas 28% occurred in areas surrounding the OR bed. CONCLUSION: The similarity of the movement and flow disruption patterns, despite variations in OR layout, highlighted the adjacencies required between major zones that CNs regularly visit. These optimum adjacencies should be considered while designing ORs such that they are more efficient and safer.

An Assessment of Levels of Safety in Psychiatric Units.

OBJECTIVES: This article aims to understand the incident patterns in relation to different types of spaces within a psychiatric unit, which are discussed using the five levels of safety framework. BACKGROUND: Implementing measures to improve patient safety is essential particularly in a psychiatric hospital, where limited research has been conducted on inpatient safety. Therefore, this article aims to understand the incident patterns from the lens of the five levels of safety framework, which categorizes spaces according to the level of patient supervision in psychiatric facilities, as follows: service areas, corridors, dayrooms, patient rooms and bathrooms, seclusions and admissions. METHODS: In an 81-bed psychiatric hospital, this mixed-method study drew 7 years of incident reports and caregivers' perceptions gathered through focus groups. Incident reports on physical safety were analyzed based on the five levels of safety framework ( N = 1,316). Focus groups ( n = 9) explored the caregivers' viewpoints on patient safety and five categories of spaces. RESULTS: Overall findings support the five levels of safety pattern, confirming that most incidents occurred in patient rooms and bathrooms; moreover, relatively fewer incidents happened in dayrooms and corridors. Elopements are higher in hallways and dayrooms. Suicide is most common in patient rooms and bathrooms, and violence is more frequent in dayrooms. Focus groups results yielded insightful recommendations. CONCLUSIONS: Levels of safety framework can be adapted to seven categories where seclusion room and admission area would be two of the spaces with least incidents.