Type of unintended consequence | Example | |
---|---|---|
Workflow changes | ▸ New work demands for clinicians ▸ Need to continuously interact with the system ▸ Overdependence on the technology ▸ Changes in communication patterns between staff ▸ Data entry that was previously performed by staff now must be performed by clinicians.56 ▸ Availability and placement of workstations can impair clinician efficiency.40 ▸ Need to enter all medication orders via CPOE can limit ability to obtain medications in an emergency.43 ▸ Communication between physicians and nurses may decrease after CPOE implementation. | |
New safety hazards | ▸ System design problems ▸ Alert fatigue ▸ Workarounds to avoid perceived or actual problems with the new system ▸ Problems relating to transitioning between different types of CPOE systems ▸ Confusing displays or inflexible ordering formats may increase the likelihood of prescribing errors.57 ▸ Continued exposure to warnings results in clinicians overriding even high-severity alerts.30 ▸ Clinicians may develop alternate computer- or paper-based workflows separate from those intended by the system manufacturers.58 ▸ Each time a new or updated system is implemented, users must familiarise themselves with new workflows.59 |
CDSS, clinical decision support systems; CPOE, computerised provider order entry.