Bordley et. al.’s paper in Critical Care Medicine (Oct 18), showcases the use of simulation to understand the recognition of latent patient safety issues in the ICU. The study assessed interprofessional ICU rounding teams as they prepared for and discussed two simulated patient cases.
They found that teams averaged nearly 70% recognition of the total safety issues, which is over twice the rate of error recognition of individual providers who assess the cases independently (32%).
Figure 1. B. Shows the rates of recognizing the different latent errors present in the medical record of the two simulated cases. It is interesting to see the differences in recognition among the different types of care providers (reinforcing the value of interprofessional care teams) and to see which safely issues are nearly always missed.
Supplementary Figure 3. Shows the average number of EHR screens viewed by each provider type. The large number of screens needed to be viewed once again supports the need for better EHR design. We need EHR’s that highlight the right data, for the right task, to the right user, and at the right time (for example).