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DOI: 10.15265/IY-2016-014
The Unintended Consequences of Health Information Technology Revisited
Correspondence to:
Publikationsverlauf
10. November 2016
Publikationsdatum:
06. März 2018 (online)
Summary
Introduction: The introduction of health information technology into clinical settings is associated with unintended negative consequences, some with the potential to lead to error and patient harm. As adoption rates soar, the impact of these hazards will increase.
Objective: Over the last decade, unintended consequences have received great attention in the medical informatics literature, and this paper seeks to identify the major themes that have emerged.
Results: Rich typologies of the causes of unintended consequences have been developed, along with a number of explanatory frameworks based on socio-technical systems theory. We however still have only limited data on the frequency and impact of these events, as most studies rely on data sets from incident reporting or patient chart reviews, rather than undertaking detailed observational studies. Such data are increasingly needed as more organizations implement health information technologies. When outcome studies have been done in different organizations, they reveal different outcomes for identical systems. From a theoretical perspective, recent advances in the emerging discipline of implementation science have much to offer in explaining the origin, and variability, of unintended consequences.
Conclusion: The dynamic nature of health care service organizations, and the rapid development and adoption of health information technologies means that unintended consequences are unlikely to disappear, and we therefore must commit to developing robust systems to detect and manage them.
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Keywords
Safety - error - electronic health records - computer provider order entry - human-computer interaction - incident reporting.
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References
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- 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.
Correspondence to:
-
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.