Understanding Clinical Decision Support Failures in Pediatric Intensive Care Units via Applied Systems Safety Engineering and Human Factors Problem Analysis: Insights From the DISCOVER Learning Lab
The application of a systems safety engineering and human factors approach to problem analysis, partnered with novel use of immersive VR and digital twin technology, led to valuable insights into common failure modes and potential opportunity areas to improve diagnostic accuracy and care delivery in a quaternary referral center PICU.
Authors
- Bain Butcher
- Andrea Meisman (ORCID: https://orcid.org/0000-0002-9594-8085)
- Kelly L. Collins (ORCID: https://orcid.org/0000-0002-2655-121X)
- Christina L. Cifra (ORCID: https://orcid.org/0000-0002-7449-802X)
- José Roberto Generoso (ORCID: https://orcid.org/0000-0002-0602-1481)
- Daniel D. Loeb (ORCID: https://orcid.org/0000-0001-5034-4037)
- Maya Dewan (ORCID: https://orcid.org/0000-0002-9966-3845)
- Colleen M. Badke (ORCID: https://orcid.org/0000-0002-7822-1669)
- Matthew Zackoff (ORCID: https://orcid.org/0000-0002-0639-8748)
- K. James
- Anabel Graciela
- Karina Ortega
Institutions
- Cincinnati Children's Hospital Medical Center (US)
- Boston Children's Hospital (US)
- Lurie Children's Hospital (US)
- University of Cincinnati (US)
- University of Cincinnati Medical Center (US)
Publication Details
- Journal
- Journal of Patient Safety
- Published
- 2025-09-23
- DOI
- https://doi.org/10.1097/pts.0000000000001358
- Primary Topic
- Clinical Reasoning and Diagnostic Skills
- Type
- article
- Field-Weighted Citation Impact
- 0.00