A b s t r a c t Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means to achieving it. As researchers conducting separate studies in the United States, The Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their different social science perspectives (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors fall into two main categories: those in the process of entering and retrieving information, and those in 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. Medical error reduction is an international issue. The Institute of Medicine's report on medical errors 1 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.'' 2 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. 4 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. 5 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. 6-8 Among the broad array of health informatics applications, CPOE systems, and especially medication systems, have received the most attention. [9] [10] [11] [12] PCISs are complicated technologies, often encompassing millions of lines of code written by many different individuals. The interaction space 13 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. [13] [14] [15] [16] [17]
In addition, it is important to be aware of unintended consequences that may occur with health IT use during the process of entering and retrieving information and during the communication and coordination process that the technology is meant to support REF .
Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors
Journal of the American Medical Informatics Association : JAMIA
Journal of the American Medical Informatics Association : JAMIA
Computer Science Medicine