Unintended consequences

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Several researchers conducting separate studies in the United States, The Netherlands, and Australia, using similar qualitative methods to investigate implementing patient care information systems (PCIS), have encountered many instances in which these applications seem to foster errors rather than reduce their likelihood.

The errors fall into two main categories:

  1. The process of entering and retrieving information
  2. The communication and coordination process that the PCIS is supposed to support


The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.

Related articles

Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004 Mar-Apr;11(2):104-12.

More can be read at The Unintended Consequences of Computerized Provider Order Entry: Findings From a Mixed Methods Exploration

Unintended Consequences associated with Health Information Technology implementations abound. Over the past few years there have been several highly-publicized articles, for example:

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.

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

Prior to HIS installation, it was common practice for residents to tell 4th year medical students (ie subintern), "Go write these orders and I'll cosign them later.". It was against hospital policy but it was done all the time. The nurses would look at the orders and say "Oh, a med student wrote for colace, I can give that." or "Oh, a med student wrote for digoxin. I better wait till it's cosigned."

When the new IT system was put in place the hospital administrators said, "Finally, we can enforce our policy."

Instead, what happened was the resident now said, "Take my key and password and go write these orders." Now the nurse says, "Oh the resident wrote the orders, I better give these meds."

Within two months the hospital policy was changed to reflect reality. 4th year medical students were allowed to write orders on their own login and nurses where required to wait for the electronic co-signature by the resident.

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

Nurses report during the transition to full CPOE implementation, they must work with a hybrid system, where some orders are entered via the CPOE system, and others are placed on paper (for example, an order for an angioplasty may be written instead of entered on the system). As more and more units "go live," there is an increasing tendency to look only at orders that are on line and to forget to double-check the paper record in case separate orders have been entered there. Furthermore, there are few redundant checks (via a unit secretary) to assure that all orders are seen by the appropriate person.

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.

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