BMJ Open 3:e002549 doi:10.1136/bmjopen-2013-002549
  • Health informatics
    • Research

Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study

  1. Jeffrey A Gold2
  1. 1Department of Hospital Medicine, Oregon Health and Science University, Portland, Oregon, USA
  2. 2Department of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
  3. 3Department of Medical Informatics & Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA
  1. Correspondence to Dr Jeffrey A Gold; goldje{at}
  • Received 3 January 2013
  • Revised 13 March 2013
  • Accepted 18 March 2013
  • Published 10 April 2013


Objective To establish the role of high-fidelity simulation training to test the efficacy and safety of the electronic health record (EHR)–user interface within the intensive care unit (ICU) environment.

Design Prospective pilot study.

Setting Medical ICU in an academic medical centre.

Participants Postgraduate medical trainees.

Interventions A 5-day-simulated ICU patient was developed in the EHR including labs, hourly vitals, medication administration, ventilator settings, nursing and notes. Fourteen medical issues requiring recognition and subsequent changes in management were included. Issues were chosen based on their frequency of occurrence within the ICU and their ability to test different aspects of the EHR–user interface. ICU residents, blinded to the presence of medical errors within the case, were provided a sign-out and given 10 min to review the case in the EHR. They then presented the case with their management suggestions to an attending physician. Participants were graded on the number of issues identified. All participants were provided with immediate feedback upon completion of the simulation.

Primary and secondary outcomes To determine the frequency of error recognition in an EHR simulation. To determine factors associated with improved performance in the simulation.

Results 38 participants including 9 interns, 10 residents and 19 fellows were tested. The average error recognition rate was 41% (range 6–73%), which increased slightly with the level of training (35%, 41% and 50% for interns, residents, and fellows, respectively). Over-sedation was the least-recognised error (16%); poor glycemic control was most often recognised (68%). Only 32% of the participants recognised inappropriate antibiotic dosing. Performance correlated with the total number of screens used (p=0.03).

Conclusions Despite development of comprehensive EHRs, there remain significant gaps in identifying dangerous medical management issues. This gap remains despite high levels of medical training, suggesting that EHR-specific training may be beneficial. Simulation provides a novel tool in order to both identify these gaps as well as foster EHR-specific training.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

blog comments powered by Disqus