Fourteen errors developed throughout the 5-day ICU course
| Error safety issue | EHR category |
|---|---|
| Changes in patient condition | |
| 25% Drop in mean arterial pressure, 25% increase in heart rate | Structure and time, cognition and customisation |
| Recurrent sepsis | Cognition |
| Increasing plateau pressure to >30 | Overcompleteness, data finding |
| Increase in WBC* | Structure and time, cognition and customisation |
| New fever | Structure and time, cognition and customisation |
| Medication errors | |
| Inappropriate antibiotic dose (2) | Data finding, cognition |
| Low antibiotic trough | Data finding, cognition |
| Use of D5W in hyperglycemic patient | Data finding and overcompleteness |
| Failure to adhere to best practice | |
| Glucose>200 mg/dl | Overcompleteness and data finding |
| Tidal volume of 8 cc/kg IBW in acute respiratory distress syndrome | Data finding and cognition |
| Over-sedation | Data finding |
| Lack of daily awakenings | Data finding |
| Recognition of fluid balance† | Data finding |
They include improper medication dosing or administration, failure to adhere to ICU best practices and inability to identify dangerous patient trends. EHR categories are defined as in Ash et al.46
*Net 30% increase in WBC from days 3 to 5.
†Net 16 litres positive since admission.
D5W, EHR, electronic health record; IBW, ideal body weight; ICU, intensive care unit; WBC, white blood cell count.