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

Ash, J. S.

doi:10.1197/jamia.m1471

Cited by 1,789Electronic Health Records SystemsPatient Safety and Medication ErrorsMedical Coding and Health Information

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

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Ash, J. S.·2003·Journal of the American Medical Informatics Association

DOI 10.1197/jamia.m1471PMC PMC353015

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Abstract

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, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their different social science perspectives (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors 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. The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.

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Documentation burden associated with electronic health records is linked to clinician burnout among physicians and nurses.
“Electronic health records (EHRs) are linked with documentation burden resulting in clinician burnout.”
From Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review (2021) · cites this paper as [9]
The paper says patient care information systems can add work tasks (p. 1), and its “Structure” section (p. 4) reports that elaborate data entry can take substantially longer than paper-based recording. It does not link that burden to clinician burnout among physicians or nurses. (LLM, conf=0.85)
Experimental — accuracy not yet measured
Poor accessibility of user interfaces may limit the benefits of health information systems and has been cited as a source of medical and user errors and health worker burnout.
“Poor accessibility of user interfaces may limit the benefits of health information systems and has been cited as a source of medical and user errors and health worker burnout.21–23”
From Effect of mobile application user interface improvements on minimum expected home visit coverage by community health workers in Mali: a randomised controlled trial (2021) · cites this paper as [21]
The section “Errors in the Process of Entering and Retrieving Information” (p. 3) says impractical interfaces consume clinicians’ time and make information hard to find. “Results: Categorization of Errors” (p. 3) links mismatches between systems and clinical work to errors in information handling and care delivery. The passages support the claim about limited benefits and errors, but do not establish that poor interface accessibility causes health worker burnout. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Application of AI systems in the real world may lead to many unintended outcomes, including alert fatigue, additional burdens for clinicians, disruption of interpersonal communications, and generation of specific threats requiring increased vigilance to recognize.
“Application of AI systems in the real world may lead to many unintended outcomes, including alert fatigue,131 additional burdens for clinicians, disruption of interpersonal communications, and generation of specific threats requiring increased vigilance to recognize.132”
From Artificial intelligence in diabetes management: Advancements, opportunities, and challenges (2023) · cites this paper as [132]
The introduction (p. 1) says patient care information systems can add work tasks, disrupt communication routines, and create hazards requiring vigilance to detect. These points support the outcomes attached to citation 132, but the paper discusses patient care information systems rather than AI systems specifically. Alert fatigue is attached to citation 131, not this source. (LLM, conf=0.86)
Experimental — accuracy not yet measured
It is widely accepted that alert fatigue explains high override rates.
“It is widely accepted that “alert fatigue” explains high override rates [7, 9–14].”
From Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system (2017) · cites this paper as [13]
Digital systems reduce visibility of system state and process integrity, making HIT hazards latent and detected indirectly through downstream consequences.
“Digital systems frequently mediate clinical work in ways that reduce direct visibility of system state and process integrity.”
From Why digital health fails silently: a sociotechnical theory of health information technology–related risk (2026) · cites this paper as [5]

CPOE systems prevent some types of errors while creating or propagating new ones.
“CPOE systems prevent some types of errors while creating or propagating new ones.4,5,21,22,24,25,33,54 -61”
From Types of Unintended Consequences Related to Computerized Provider Order Entry (2006) · cites this paper as [5]
Emerging evidence suggests that health information technology may cause new patient safety concerns and other unintended consequences due to usability issues, disruptions of clinical processes, and unsafe workarounds.
“However, emerging evidence suggests that HIT may cause new patient safety concerns and other unintended consequences due to usability issues, disruptions of clinical processes, and unsafe workarounds to circumvent technology-related constraints.2–16”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [3]
Building on previous approaches, the authors' categorization expands the two high-level categories of human-computer and machine-related problems identified by others.
“Building on previous approaches to examining healthcare IT incidents, our categorization expands the two high-level categories of humanecomputer and machine-related problems identified by others. 1 8”
From An analysis of computer-related patient safety incidents to inform the development of a classification (2010) · cites this paper as [1]
Two of the main categories map to the high-level error classes first identified by Ash et al.: 'Information input problems' and 'information output problems' correspond to errors in 'entering and retrieving information', and 'information transfer problems' correspond to 'communication and co-ordination'.
“Two of our main categories map to the high-level error classes first identified by Ash et al. 1 'Information input problems' and 'information output problems' correspond to errors in 'entering and retrieving information', and 'information transfer problems' correspond to 'communication and co-ordination'.”
From An analysis of computer-related patient safety incidents to inform the development of a classification (2010) · cites this paper as [1]
Technology can introduce new uncertainties and patient safety risks by disrupting established work patterns, creating new risks in practice, and encouraging workarounds.
“research suggests that technology may lead to new uncertainties and risks for patient safety through disrupting established work patterns, creating new risks in practice, and encouraging workarounds.”
From Exploring the sociotechnical intersection of patient safety and electronic health record implementation (2014) · cites this paper as [3]
IT-based interventions alone cannot assure improvements in communication.
“IT-based interventions alone, however, cannot assure improvements in communication.”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [34]
Often communication in the health care setting is not only intended to transfer information, but also to generate a response from the recipient, such as taking an action and acknowledging receipt of the information.
“In this paper, it is worthwhile to consider the goals of communication in the health care setting: often communication is not only intended to transfer information, but also to generate a response from the recipient of the information, such as taking an action and acknowledging receipt of the information.34”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [34]
Computerized information systems themselves can lead to unintended errors including those that involve communication processes.
“For instance, computerized information systems themselves can lead to unintended errors including those that involve communication processes.25,34,42”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [34]
Evidence suggests that CPOE implementation and maintenance can bring unintended negative effects.
“there is evidence that unintended adverse consequences can surround the implementation and ongoing maintenance of these systems.[8][9][10]”
From Computerized Provider Order Entry Adoption: Implications for Clinical Workflow (2009) · cites this paper as [8]

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Missed and Delayed Diagnoses in the Emergency Department: A Study of Closed Malpractice Claims From 4 Liability Insurers
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Theory of Workarounds
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Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2
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A literature review for large-scale health information system project planning, implementation and evaluation
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Interruptions in healthcare: Theoretical views
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Fumbled handoffs: one dropped ball after another
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STARE-HI—Statement on reporting of evaluation studies in Health Informatics
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Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study
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“just information transfer—it requires a response from the recipient, such as taking follow-up action and acknowledging receipt of the information to the sender.(15) Previous studies raise concern that HCPs may not read all their alerts.”
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The Revolution of Blockchain: State-of-the-Art and Research Challenges
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Patient and Physician Reminders to Promote Colorectal Cancer Screening
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Do Online Information Retrieval Systems Help Experienced Clinicians Answer Clinical Questions?
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Miller, R. A., Waitman, L. R., Chen, S., & Rosenbloom, S. T. (2005) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2005.08.009 · Cited by 144 · see citing works

Authors: Ash, J. S.
Affiliations: Oregon Health & Science University (US)
Corresponding author: Ash, J. S.
ORCID: Ash, J. S.
Venue: Journal of the American Medical Informatics Association
Publisher: Oxford University Press (OUP)
Published: 2003-11-21
Volume: 11
Issue: 2
Pages: 104-112
ISSN: 1067-5027 (ISSN-L)
1527-974X
DOI: 10.1197/jamia.m1471
PMC: PMC353015
OpenAlex: W1787211267
Cited by: 1,789
References: 86
Citations by year: 2026: 45 · 2025: 32 · 2024: 42 · 2023: 45 · 2022: 42 · 2021: 62 · 2020: 69 · 2019: 93 · 2018: 75 · 2017: 78 · 2016: 108 · 2015: 106 · 2014: 106 · 2013: 132 · 2012: 142
FWCI: 101.69
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: Journal of the American Medical Informatics Association (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Funders: U.S. National Library of Medicine (LM06942-02)
Topics: Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
Keywords: clinical information systems, medical errors, silent errors, medical error reduction, health informatics, system design and implementation
MeSH terms: Communication, Patient Care, Humans, Information Systems, Patient Care Management, User-Computer Interface, Information Storage and Retrieval, Medical Errors, Decision Support Systems, Clinical

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

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