Our data suggest that as many as 40,500 adult patients in an ICU in USA may die with an ICU misdiagnoses annually. Despite this, diagnostic errors receive relatively little attention and research funding. Future studies should seek to prospectively measure the prevalence and impact of diagnostic errors and potential strategies to reduce them.

Implementation of an ICU bundle along with staff education and case conferences is effective for improving delirium screening, detection, and treatment and is associated with decreased delirium prevalence.

Provider orders reflect dynamic changes in patients' conditions, making them useful for real-time length of stay prediction and patient flow management. Patients' length of stay represent a major source of variability in intensive care unit resource utilization and if accurately predicted and communicated, may lead to proactive bed management with more efficient patient flow.

An inadequately developed or inadequately shared mental model is a substantial cognitive limitation for expert and team cognition in the complex environment of the pediatric intensive care unit. Providers utilize techniques that may avoid or decrease the variable interpretations of patient condition that would otherwise impair mental model formation and sharing. Future studies should be designed to enhance mental model formation and communication in the pediatric intensive care unit and other environments that deal with complex patients.