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First published November 21, 2003 as JAMIA PrePrint; doi:10.1197/jamia.M1471
Journal of the American Medical Informatics Association 2004;11(2):104-112
© 2004 American Medical Informatics Association

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Submitted on October 3, 2003
Accepted on November 20, 2003

Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System Related Errors

Joan S. Ash PhD, MLS1*, Marc Berg MD, PhD2, and Enrico Coiera MBBS, PhD3

Affiliation of the authors: 1 Oregon Health & Science University, Portland, OR; 2 Erasmus University, Rotterdam, The Netherlands; 3 University of New South Wales, Sydney, Australia

* To whom correspondence should be addressed.

Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means to achieving it. As researchers conducting separate studies in the United States, The Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, we have encountered many instances where PCIS applications seem to foster errors rather than reduce their likelihood. In this paper, we describe the kinds of silent errors we have witnessed and, from our different social science perspectives (information science, sociology, and cognitive science), we interpret the nature of these errors. They fall into two main categories: those in the process of entering and retrieving information, and those in the communication and coordination process that the PCIS is supposed to support. We believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that we may be able to avoid the unintended consequences of these subtle silent errors.




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