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Dr. Sittig cited in the Joint Commission Sentinel Event Alert (Issue 42, December 11, 2008)

Safely implementing health information and converging technologies. This alert reports that, as health information technology (HIT) and converging technologies—the interrelationship between medical devices and HIT—are increasingly adopted by health care organizations, users must be mindful of the safety risks and preventable adverse events that these implementations can create or perpetuate.

Dr. Sittig’s paper (Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association, September/October 2006, 13(5):547-556) found that “Unintended adverse consequences (UACs) fell into nine major categories (in order of decreasing frequency):

  1. more/new work for clinicians;
  2. unfavorable workflow issues;
  3. never ending system demands;
  4. problems related to paper persistence;
  5. untoward changes in communication patterns and practices;
  6. negative emotions;
  7. generation of new kinds of errors;
  8. unexpected changes in the power structure; and
  9. overdependence on the technology.

Clinical decision support features introduced many of these unintended consequences.” They concluded, “Identifying and understanding the types and in some instances the causes of unintended adverse consequences associated with CPOE will enable system developers and implementers to better manage implementation and maintenance of future CPOE projects.”

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