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.

Other non-peer-reviewed examples of unintended consequences:

1. Flashing light used to notify nurses of new laboratory alerts
2. Medical students write orders that residents will co-sign later
3. Confusion over meaning of "cervical mass" e.g., re: cervix or cervical vertebrae
4. Use of common, floor-level computer login for clinical results review
5. Emergency department transfer orders canceled by system upon transfer to floor
6. X-Ray technician in room taking X-Ray before nurse is aware of order
7. Orders on paper missed in system with hybrid electronic/paper systems
8. Medications administered before pharmacy verification, because verification takes too long
9. Add your example here...