Unintended Consequences of HIT
Unintended Consequences associated with Health Information Technology implementations abound. Over the past few years there have been several highly-publicized articles, for example:
- Han YY, Carcillo JA, Venkataraman ST, Clark RSB, Watson RS, Nguyen TC, Bayir H, Orr RA. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005 Dec; 116(6): 1506-12;
- Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005 Mar 9; 293(10): 1197-203;
- Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006 Sep-Oct; 13(5): 547-556
These articles described specific cases in which HIT implementations have run up against severe unanticipated and unintended consequences. The goal of this section of the ClinfoWiki is to provide a forum for individuals to describe specific unintended consequences of HIT implementations that they have experienced.
Contents
- 1 Other non-peer-reviewed examples of unintended consequences
- 1.1 Flashing light used to notify nurses of new laboratory alerts
- 1.2 Medical students write orders that residents will co-sign later
- 1.3 Confusion over meaning of "cervical mass" e.g., re: cervix or cervical vertebrae
- 1.4 Use of common, floor-level computer login for clinical results review
- 1.5 Emergency department transfer orders canceled by system upon transfer to floor
- 1.6 X-Ray technician in room taking X-Ray before nurse is aware of order
- 1.7 Orders on paper missed in system with hybrid electronic/paper systems
- 1.8 Medications administered before pharmacy verification, because verification takes too long
- 1.9 Add your example here...
Other non-peer-reviewed examples of unintended consequences
Flashing light used to notify nurses of new laboratory alerts
Medical students write orders that residents will co-sign later
Confusion over meaning of "cervical mass" e.g., re: cervix or cervical vertebrae
Use of common, floor-level computer login for clinical results review
Emergency department transfer orders canceled by system upon transfer to floor
X-Ray technician in room taking X-Ray before nurse is aware of order
Orders on paper missed in system with hybrid electronic/paper systems
Medications administered before pharmacy verification, because verification takes too long
Nurses report being impatient with the length of time it takes for pharmacy to approve medication orders (e.g., check for drug-drug interactions, verify dosage and route, etc.). Because of the time lag, the nurses go ahead and administer the ordered meds, then check the verification afterwards. This bypasses an important safety aspect of CPOE adoption.
