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. 2007 Oct 11:2007:26-30.

Some unintended consequences of clinical decision support systems

Joan S Ash  1 , Dean F Sittig, Emily M Campbell, Kenneth P Guappone, Richard H Dykstra
Affiliations

Some unintended consequences of clinical decision support systems

Joan S Ash et al. AMIA Annu Symp Proc. .

Abstract

Clinical decision support systems (CDS) coupled with computerized physician/provider order entry (CPOE) can improve the quality of patient care and the efficiency of hospital operations. However, they can also produce unintended consequences. Using qualitative methods, a multidisciplinary team gathered and analyzed data about the unintended consequences of CPOE, identifying nine types, and found that CDS-generated unintended consequences appeared among all types. Further analysis of 47 CDS examples uncovered three themes related to CDS content: elimination or shifting of human roles; difficulty in keeping content current; and inappropriate content. Three additional themes related to CDS presentation were found: rigidity of the system; alert fatigue; and potential for errors. Management of CDS must include careful selection and maintenance of content and prudent decision making about human computer interaction opportunities.

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References

    1. Bates DW, Kuperman GJ, Wang S, et al. Ten commandments for effective clinical decision support: Making the practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003;10(6):523–30. - PMC - PubMed
    1. Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle J. High rates of adverse drug events in a highly computerized hospital. Arch Int Med. 2005;165(10):1111–6. - PubMed
    1. Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506–12. - PubMed
    1. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Int Med. 2003;163(12):1409–1416. - PubMed
    1. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311–1216. - PubMed

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