The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration

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The authors contend that when they started their study the area of unintended consequences of computerized provider order entry CPOE was discussed infrequently. One study of a similar type of system, bar code medication, in the VA system identified side effects of CPOE which could lead to adverse drug events ADE. The bar code system was supposed to prevent ADEs but the VA study documented several unintended issues that could lead to errors. Prevention of medication errors was thought to be one of the prime benefits of CPOE but other researchers also began to see unintended consequences. The term “unintended consequences” UC) was coined in a summary paper by Ash, et. al [1]


The article discussed the foci, activities, methods and results of a four year project which identified unintended consequences contributed to CPOE usage. [1]


The Provider Order Entry Team (POET) researchers based in Oregon conducted a 4 year study using both qualitative and quantitative methods. Five organizations with a reputation for excellence in using clinical systems were selected. The organizations had to agree to share and the surprises they saw and managed and to allow observation during order entry process. The data was collected by direct observation, interviews, short surveys and conference discussion by experts. The 390 examples of unintended consequences gathered from fieldwork, surveys and conferences were categorized into 9 types: [1]

  • More/new work issues
  • Workflow issues
  • Never ending demands
  • Paper persistence
  • Communication issues
  • Emotions
  • New kinds of errors
  • Changes in the power structure
  • Over dependence

The categories of UCs were affirmed by experts who recommended the development of tools to assist in mitigating the unintended consequences. Surveys and interviews related to the categorized UC types were then conducted at other acute care and VA hospitals. Responding hospitals reported these categorized types of unintended consequences (UC) are common. The survey results verified the UCs and analysis of the comments provided valuable insight for some of the causes. The analysis facilitated the identification of best practice guidelines, development of checkup tools and the creation of dashboard tools useful in managing unintended consequences.


The authors concluded the methods utilize in the study were worked well and they were able to develop the taxonomy of the types of unintended consequences (UCs) and make sound recommendations on how to manage them.

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  1. 1.0 1.1 1.2 Ash, J., Sittig, D., Dykstra, R., Campbell, E., Guappone, K. (2009). The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration.Journal of the American Medical Informatics Association. doi:10.1016/j.ijmedinf.2008.07.015