Example 9: Despite Testing, Unintended Consequences Can Still Occur

Issues Encountered

After a year of testing at multiple sites, a large integrated health system was ready to roll out a systemwide software update for its EHR. Not long after the update, users reported that physician orders to stop medications had gone missing. The "missing" stop orders had caused some patients to receive intravenous medications longer than necessary.

Finding a Solution

Upon further review it was discovered that the stop orders were not, in fact, missing, but were simply displayed less prominently on a different portion of the computer screen. The nurses had grown accustomed to the stop orders being positioned at the top of the screen and did not see the orders once their position was altered. Once the problem was identified, it was quickly corrected.

To minimize unintended consequences of EHR updates, organizations need to ensure the following:

  • The vendor and local IT have thoroughly tested the updated software
  • The vendor or local IT provides documentation of all known ways the software update will change the EHR functionality
  • Clinical users are aware of the changes in functionality
  • The channels necessary to receive user feedback are open and users feel empowered to provide feedback
  • Users are made aware of any unanticipated changes in functionality as soon as they become evident

Lessons Learned

  • Despite lengthy testing of the software updates, problems may still emerge after implementation.
  • Clinical users are the frontline for detecting unintended consequences that are not discovered during system testing.
  • Be on high alert for changes in user behavior, which may reflect unintended consequences of software changes.
  • If user behavior does change, carefully consider how these changes could impact patient care.

Source: Kuehn BM. IT Vulnerabilities Highlighted by Errors, Malfunctions at Veterans' Medical Centers, JAMA 2009. Mar 4; 301(9): 919-20.

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