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

https://pmc.ncbi.nlm.nih.gov/articles/PMC12453092/ Study Uses Virtual Reality To Assess Clinical Decision Support in Pediatric ICU Using a novel systems approach and virtual reality observation method, an AHRQ-funded Patient Safety Learning Lab study has pinpointed key challenges in the use of clinical decision support (CDS) in the pediatric intensive care unit. Common issues included poor communication, workflow inefficiencies, limited real-time access to clinical data, and consistent clinician disregard for existing in-room CDS tools. Researchers mapped unit workflows and conducted qualitative interviews, then tested clinician behavior in an immersive virtual reality "digital twin" of the unit. A subsequent failure modes and effects analysis revealed failures related to information flow, diagnostic accuracy, and situation awareness. These findings indicate opportunities for predictive, intuitive, and seamlessly integrated CDS design, supported by systems safety and human factors principles