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PSNet: Patient Safety Network
Journal Article

Types of unintended consequences related to computerized provider order entry.

Campbell EM, Sittig DF, Ash JS, et al. Journal of the American Medical Informatics Association : JAMIA. 2006;13:547-56.

This qualitative study describes the capture and analysis of computerized provider order entry (CPOE)–related events from five different CPOE sites. Building on an initial set of examples from an expert panel, investigators designed a 9-category classification scheme for nearly 325 unintended consequences reported. The most frequent unintended consequences included more or new work for clinicians, workflow issues, and never-ending system demands. The authors discuss strategies to address each of the categories and explain the importance of understanding these issues to advance management of future CPOE applications. A past study and commentary discussed the need for caution with implementation of CPOE systems in light of similar concerns and available research.