Yearbook of Medical Informatics, Inhaltsverzeichnis Yearb Med Inform 2016; 25(01): 163-169DOI: 10.15265/IY-2016-014 IMIA and Schattauer GmbH Georg Thieme Verlag KG StuttgartThe Unintended Consequences of Health Information Technology Revisited Authors Institutsangaben E. Coiera 1 Australian Institute of Health Innovation, Macquarie University, Australia J. Ash 2 Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, USA M. Berg 3 Principal, Advisory, KPMG LLP (US) Artikel empfehlen Abstract Volltext als PDF herunterladen(opens in new window) Keywords KeywordsSafety - error - electronic health records - computer provider order entry - human-computer interaction - incident reporting. Referenzen References 1 Coiera E. Putting the technical back into socio-technical systems research.. Int J Med Inform 2007; 76: S98-S103. 2 Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors.. J Am Med Inform Assoc 2004; 11: 104-12. 3 Ash J. Organizational factors that influence information technology diffusion in academic health sciences centers.. J Am Med Inform Assoc 1997; 4 (Suppl. 02) 102-11. 4 Berg M. Rationalizing medical work: decision-support techniques and medical practices.. MIT press; 1997 5 Coiera E. When conversation is better than computation.. J Am Med Inform Assoc 2000; 7 (Suppl. 03) 277-86. 6 Foundation NPS. Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human.. Boston, MA: National Patient Safety Foundation; 2015 7 Coiera E, Aarts J, Kulikowski C. The dangerous decade.. J Am Med Inform Assoc 2012; 19: 2-5. 8 Magrabi F, Ong MS, Runciman W, Coiera E. Patient safety problems associated with heathcare information technology: an analysis of adverse events reported to the US Food and Drug Administration.. AMIA Annu Symp Proc 2011; 853-7. 9 Ash JS, Sittig DF, Dykstra RH, Guappone K, Carpenter JD, Seshadri V. Categorizing the unintended sociotechnical consequences of computerized provider order entry.. Int J Med Inform 2007; Jun 76 Suppl 1: S21-7. 10 Yu P, Zhang Y, Gong Y, Zhang J. Unintended adverse consequences of introducing electronic health records in residential aged care homes.. Int J Med Inform 2013; 82 (Suppl. 09) 772-88. 11 Novak LL, Holden RJ, Anders SH, Hong JY, Karsh BT. Using a sociotechnical framework to understand adaptations in health IT implementation.. Int J Med Inform 2013; Dec 82 (Suppl. 012) e331-44. 12 Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.. J Am Med Inform Assoc 2008; 15 (Suppl. 04) 408-23. 13 Kuperman G, McGowan J. Potential Unintended Consequences of Health Information Exchange.. J Gen Intern Med 2013; 28 (Suppl. 12) 1663-66. 14 Richardson JE, Ash JS. The effects of hands-free communication device systems: communication changes in hospital organizations.. J Am Med Inform Assoc 2010; 17 (Suppl. 01) 91-8. 15 Hodgson T, Coiera E. Risks and benefits of speech recognition for clinical documentation: a systematic review.. J Am Med Inform Assoc 2016; Apr 23 (Suppl. 01) e169-79. 16 Magrabi F, Ong MS, Runciman W, Coiera E. Using FDA reports to inform a classification for health information technology safety problems.. J Am Med Inform Assoc 2012; 19 (Suppl. 01) 45-53. 17 Magrabi F, Liaw ST, Arachi D, Runciman W, Coiera E, Kidd MR. Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports.. BMJ Qual Saf 2015 Nov 5. 18 Magrabi F, Ong M-S, Runciman W, Coiera E. An analysis of computer-related patient safety incidents to inform the development of a classification.. J Am Med Inform Assoc 2010; NovDec 17 (Suppl. 06) 663-70. 19 Magrabi F, Baker M, Sinha I, Ong MS, Harrison S, Kidd MR. et al. Clinical safety of England’s national programme for IT: A retrospective analysis of all reported safety events 2005 to 2011.. Int J Med Inform 2015; Mar 84 (Suppl. 03) 198-206. 20 Schiff G, Amato M, Eguale T, Boehne JJ, Wright A, Koppel R. et al. Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems.. BMJ Qual Saf 2015; Apr 24 (Suppl. 04) 264-71. 21 Turchin A, Shubina M, Goldberg S. Unexpected Effects of Unintended Consequences: EMR Prescription Discrepancies and Hemorrhage in Patients on Warfarin.. AMIA Annu Symp Proc 2011; 2011: 1412-17. 22 Reckmann MH, Westbrook JI, Koh Y, Lo C, Day RO. Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review.. J Am Med Inform Assoc 2009; Sep-Oct 16 (Suppl. 05) 613-23. 23 Slight SP, Eguale T, Amato MG, Seger AC, Whitney DL, Bates DW. et al. The vulnerabilities of computerized physician order entry systems: a qualitative study.. J Am Med Inform Assoc 2016; Mar 23 (Suppl. 02) 311-6. 24 Strom BL, Schinnar R, Aberra F, Bilker W, Hennessy S, Leonard CE. et al. Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.. Arch Intern Med 2010; 170 (Suppl. 17) 1578-83. 25 Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of Unintended Consequences Related to Computerized Provider Order Entry.. J Am Med Inform Assoc 2006; 13 (Suppl. 05) 547-56. 26 Weiner JP, Kfuri T, Chan K, Fowles JB. “e-Iatrogenesis”: The Most Critical Unintended Consequence of CPOE and other HIT.. J Am Med Inform Assoc 2007; 14 (Suppl. 03) 387-8. 27 Institute of Medicine.. Health IT and Patient Safety: Building Safer Systems for Better Care.. The National Academies Press; 2012 28 Miller M, Clark J, Lehmann C. Computer based medication error reporting: insights and implications.. Qual Saf Health Care 2006; 15 (Suppl. 03) 208-13. 29 Shojania KG. The frustrating case of incident-reporting systems.. Qual Saf Health Care 2008; 17 (Suppl. 06) 400-02. 30 Hewett R, Kulkarni A, Seker R, Stringfellow C. On effective use of reliability models and defect data in software development.. Region 5 Conference, 7–9 April 2006 IEEE, San Antonio, TX, USA. 2006 p. 67-71. 31 Stringfellow C, Andrews A, Wohlin C, Petersson H. Estimating the number of components with defects post-release that showed no defects in testing.. Software Testing, Verification and Reliability 2002; 12 (Suppl. 02) 93-122. 32 Walsh KE, Adams WG, Bauchner H, Vinci RJ, Chessare JB, Cooper MR. et al. Medication Errors Related to Computerized Order Entry for Children.. Pediatrics 2006; 118 (Suppl. 05) 1872-9. 33 Westbrook JI, Reckmann M, Li L, Runciman WB, Burke R, Lo C. et al. Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study.. PLoS Med 2012; 9 (Suppl. 01) e1001164. 34 Westbrook JI, Baysari MT, Li L, Burke R, Richardson KL, Day RO. The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals.. J Am Med Inform Assoc 2013; 20 (Suppl. 06) 1159-67. 35 Ong MS, Magrabi F, Coiera E. Syndromic surveillance for health information system failures: a feasibility study.. J Am Med Inform Assoc 2012; 20 (Suppl. 03) 506-12. 36 Adelman JS, Kalkut GE, Schechter CB, Weiss JM, Berger MA, Reissman SH. et al. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.. J Am Med Inform Assoc 2013; 20 (Suppl. 02) 305-10. 37 Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC. et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.. Pediatrics 2005; 116 (Suppl. 06) 1506-12. 38 Del Beccaro MA, Jeffries HE, Eisenberg MA, Harry ED. Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.. Pediatrics 2006; 118 (Suppl. 01) 290-95. 39 Longhurst CA, Parast L, Sandborg CI, Widen E, Sullivan J, Hahn JS. et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system.. Pediatrics 2010; 126 (Suppl. 01) 14-21. 40 Keene A, Ashton L, Shure D, Napoleone D, Katyal C, Bellin E. Mortality before and after initiation of a computerized physician order entry system in a critically ill pediatric population.. Pediatr Crit Care Med 2007; 8 (Suppl. 03) 268-71. 41 Rosenbloom ST, Harrell FE, Lehmann CU, Schneider JH, Spooner SA, Johnson KB. Perceived increase in mortality after process and policy changes implemented with computerized physician order entry.. Pediatrics 2006; 117 (Suppl. 04) 1452-55. 42 Coiera E. Guide to Health Informatics (3rd Edition).. 3rd ed. London: CRC Press; 2015 43 Braithwaite J, Coiera E. Beyond patient safety Flatland.. J R Soc Med 2010; 103 (Suppl. 06) 219-25. 44 Hollnagel E, Braithwaite J, Wears RL. Resilient health care.. Ashgate Publishing, Ltd.; 2013 45 Novak LL, Holden RJ, Anders SH, Hong JY, Karsh BT. Using a sociotechnical framework to understand adaptations in health IT implementation.. Int J Med Inform 2013; 82 (Suppl. 12) e331-e44. 46 Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems.. Qual Saf Health Care 2010; 19 (Suppl. 03) i68-i74. 47 Sittig DF, Ash JS, Singh H. ONC issues guides for SAFER EHRs.. J AHIMA 2014; 85: 50-2. 48 Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care—an interactive sociotechnical analysis.. J Am Med Inform Assoc 2007; 14 (Suppl. 05) 542-9. 49 Koppel R. The health information technology safety framework: building great structures on vast voids.. BMJ Qual Saf 2016; Apr 25 (Suppl. 04) 218-20. 50 Lau AYS, Coiera EW. Do People Experience Cognitive Biases while Searching for Information?. J Am Med Inform Assoc 2007; 14 (Suppl. 05) 599-608. 51 Brown GD, Matthews WJ. Decision by Sampling and Memory Distinctiveness: Range Effects from Rank-Based Models of Judgment and Choice.. Front Psychol 2011; 2: 299. 52 Coiera E, Westbrook JI, Wyatt JC. The Safety and Quality of Decision Support Systems.. Methods Inf Med 2006; 45 (Suppl. 01) S20-5. 53 Goddard K, Roudsari A, Wyatt JC. Automation bias: a systematic review of frequency, effect mediators, and mitigators.. J Am Med Inform Assoc 2012; 19 (Suppl. 01) 121-7. 54 Coiera E. Technology, cognition and error.. BMJ Qual Saf 2015; 24 (Suppl. 07) 417-22. 55 Wickens C, Hollands J, Parasuraman R. Engineering Psychology and Human Performance.. 4th ed. New Jersey: Pearson; 2012 56 Skitka L, Mosier K, Burdick M, Rosenblatt B. Automation bias and errors: are crews better than individuals.. Int J Aviat Psychol 2000; 10 (Suppl. 01) 85-97. 57 Lau AYS, Coiera EW. Can Cognitive Biases during Consumer Health Information Searches Be Reduced to Improve Decision Making?. J Am Med Inform Assoc 2009; 16 (Suppl. 01) 54-65. 58 Koppel R, Lehmann CU. Implications of an emerging EHR monoculture for hospitals and healthcare systems.. J Am Med Inform Assoc 2015; 22 (Suppl. 02) 465-71. 59 Coiera E. The science of interruption.. BMJ Qual Saf 2012; 21 (Suppl. 05) 357-60. 60 Sweller J, Ayres P, Kalyuga S. Cognitive load theory.. Springer;; 2011 61 Sintchenko VS, Coiera E. Decision complexity affects the extent and type of decision support use.. AMIA Annu Symp Proc; 2006; 724-8. 62 Coiera E. Communication spaces.. J Am Med Inform Assoc 2014; 21 (Suppl. 03) 414-22. 63 Eccles M, Mittman B. Welcome to Implementation Science.. Implement Sci 2006; 1 (Suppl. 01) 1.
