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Unintended Consequences

CS855 Phase 2 IP

Unintended Consequences of the Patient Care Information System

The Patient Care Information System (PCIS) was a system developed to record patient information in hospitals in The Netherlands, Australia, and the U.S. During and study of the application of the system (Ash, Berg and Coiera, 2004) the authors discovered problems within the system. These problems were not noticed because of the nature of the errors. The intention of the system was to reduce errors. PCIS was implemented to keep records accurate and available to the medical community.

The authors noted that the system contained a great deal of development and it was not possible to predict how the system would react to all the complex interactions and problems that would be faced. During the research the authors found that most of the administrators of the system felt the system was highly accurate, but during the study (Ash, Berg and Coiera, 2004) it was found users and administrators actually had a great deal of fear and denial of the lack of accuracy. It was found that a system could be helpful as a way to make forms and computerize routine activities. However, healthcare and the predictions of the course of care were difficult to automate. Patients were found to have unique paths were impossible to code into software. Healthcare professionals found that entering data did not support the qualitative judgments that followed a line of care, and a patient’s best route to health. This confusion created mistakes as users tried to best guess the input desired by the system. The users were aware, but afraid of the possible errors and continued the mistaken paths of recording and assigning healthcare.

The study concluded that the rigidity of the system and the instance of form completion created a system of working within the PCIS system rather than focusing on healthcare. Users were frustrated with the systems inability to be flexible in the data entry. Knowingly the system was no trusted and the final patient healthcare was compromised. The data points entered into the system was long and complicated Users had an effect on patient health accuracy through making entry errors. The system’s intention to automate and help the healthcare system created and atmosphere of computerized data. Before the system was implemented a call was made remove human error from healthcare (Hendee, n.d.). However the results were not was desirable. The PCIS system had the best of intentions, but the outcomes actually compromised the health of many patients and cause concern for PCIS as reliable and helpful method from predicting future processes for individual patients.

Although the system was designed to alleviate errors in healthcare the PCIS actually had the opposite outcome. Due to complicated and long forms, the users of the system were not allowed to accurately evaluate healthcare of human patients. The authors (Ash, Berg and Coiera, 2004) discovered through the study an opposite outcome of patient care. In the end the system became the focus of the healthcare, not the patients. This was not the intention of course, but the unintended outcomes were the opposite of the intended outcomes. The government’s desire to treat patients through technological innovation and support did not take into account the complexities of patient care. Those that treat health issues make many decisions based on observations that currently cannot be part of an automated system. To address the complexities the PCIS ended up being to complicate for users to use and control. The system became the frustration, not the healthcare issues that were supposed to help. The technology ended up getting more in the way, as proposed to solving a real problem.


Ash, J., Berg, M., & Coiera, E. (2004, March 1). Some unintended consequences of information technology in health care: The nature of patient care information system-related rrrors.

Hendee, W. (n.d.). To Err is Human: Building a Safer Health System. Journal of Vascular and Interventional Radiology, P112-P113.

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