Some Unintended Consequences of Information Technology in Health Care : The Nature of Patient Care Information System-related Errors

j J Am Med Inform Assoc. 2004;11:104–112. DOI 10.1197/jamia.M1471. Medical error reduction is an international issue. The Institute of Medicine’s report on medical errors dramatically called attention to dangers inherent in the U.S. medical care system that might cause up to 98,000 deaths in hospitals and cost approximately $38 billion per year. In the United Kingdom, the chief medical officer of the newly established National Patient Safety Agency estimates that ‘‘850,000 incidents and errors occur in the NHS each year. ’’ In The Netherlands, the exact implications of the U.S. figures for the Dutch health care scene are much debated. There as well, however, patient safety is on its way to becoming a political priority. Medication errors alone have been estimated to cause 80,000 hospital admissions per year in Australia, costing $350 million. In much of the literature on patient safety, patient care information systems (PCISs) are lauded as one of the core building blocks for a safer health care system. PCISs are broadly defined here as applications that support the health care process by allowing health care professionals or patients direct access to order entry systems, medical record systems, radiology information systems, patient information systems, and so on. With fully accessible and integrated electronic patient records, and with instant access to up-to-date medical knowledge, faulty decision making resulting from a lack of information can be significantly reduced. Likewise, computerized provider order entry (CPOE) systems and automated reminder systems can reduce errors by eliminating illegible orders, improving communication, improving the tracking of orders, checking for inappropriate orders, and reminding professionals of actions to be undertaken. In this way, these systems can contribute to preventing under-, over-, or misuse of diagnostic or therapeutic interventions. Among the broad array of health informatics applications, CPOE systems, and especially medication systems, have received the most attention. PCISs are complicated technologies, often encompassing millions of lines of code written by many different individuals. The interaction space within which clinicians carry out their work can also be immensely complex, because individuals can execute their tasks by communicating across rich social networks. When such technologies become an integral part of health care work practices, we are confronted with a large sociotechnical system in which many behaviors emerge out of the sociotechnical coupling, and the behavior of the overall system in any new situation can never be fully predicted from the individual social or technical components. It is not surprising, therefore, that authors have started to describe some of the unintended consequences that the implementation of PCISs can trigger. For instance, professionals could trust the decision support suggested by the seemingly objective computer more than is actually Affiliations of the authors: Oregon Health & Science University, Portland, OR (JSA); Erasmus University, Rotterdam, The Netherlands (MB); University of New South Wales, Sydney, Australia (EC). This work was supported in part by grant LM06942-02 from the National Library of Medicine. The authors appreciate the valuable contributions of Sophie Gosling and Johanna Westbrook from the Center for Health Informatics, University of New South Wales, who shared their Australian data, and Richard Dykstra, Lara Fournier, and Veena Seshadri of Oregon Health & Science University for analysis of U.S. data. Correspondence and reprints: Joan S. Ash, PhD, Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098; e-mail: <ash@ohsu.edu>. Received for publication: 10/03/03; accepted for publication: 10/27/03. 104 ASH ET AL., Unintended Consequences of Information Technology