1(-0“All practice errors can not be attributed to the humancauses of ignorance and avarice. Thus, I conclude thatthough the individual physician is not perfectable, thesystem of care is, and that the computer will play amajor part in the perfection of future care systems.”
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7KH /DZ RI 8QLQWHQGHG &RQVHTXHQFHVThe “Law of UnintendedConsequences” encapsulatesthe idea that almost all humanactions have at least oneunintended consequence,where an action results in anoutcome that is not (or notonly) what is intended.
CPOE in a Children’s Hospital 8QH[SHFWHG,QFUHDVHG 0RUWDOLW THE INFORMED PATIENT By LAURA LANDRO $IWHU Tech Glitches Can Slow Patient,PSOHPHQWDWLRQ RI D Care &RPPHUFLDOO 6ROG New Computers May Deliver Turmoil When They Arrive; &RPSXWHUL]HG One Study Cites Death Rates 3KVLFLDQ 2UGHU December 28, 2005; Page D6 (QWU 6VWHP A controversial study linking an increased death rate to the installation of a new computerYong Y. Han, et al. Pediatrics 2005; 116; 1506-1512 system at Childrens Hospital of Pittsburgh reinforces growing…
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8$& 8QIDYRUDEOH :RUNIORZ ,VVXHV Problem Modeling clinical workflows is difficult because clinical practice is so inherently complex, interruption-driven, and constantly changing. 5HFRPPHQGDWLRQ Recognize that no EMR system fits all workflows of a given hospital perfectly. Even if a system initially did so, it would not eliminate the need for constant system adaptation to changing workflows in the future. Realize that whenever there are adjustments, there will be unintended consequences.
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8$& 1HYHU (QGLQJ 6VWHPHPDQGV Problem EMR systems evolve (i.e., are reconfigured, enhanced, or replaced) over time, making hardware and software upgrades a necessity. As changes occur, users must be retrained and quality assurance measures must be reassessed. 5HFRPPHQGDWLRQ With each change, implementers should expect unintended consequences. Although these consequences can be anticipated, their extent is typically underestimated. Adequate resources must be allocated for these ongoing improvements!
8$& 1HYHU (QGLQJ 6VWHPHPDQGV“EMR maintenance is likerepairing a jet engine in flightbecause the consequences ofmaking mistakes are ordersof magnitude greater than forless-integrated clinicalsystems.”
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