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E-Iatrogenesis

What is E-Iatrogenesis? It is "patient harm caused at least in part by the application of health information technology" according to Weiner et al (2007).  These are unintended errors from the intended design of healthcare information systems as users interact with systems differently than anticipated. E-iatrogenesis, or technological iatrogenesis, represents the fourth kind of iatrogenesis (in addition to clinical, social and cultural).

The Joint Commission issued a Sentinel Event Alert on December 11, 2008 for the use of healthcare information technology noting that approximately 25 percent of medication errors involved some aspect of computer technology as at least one cause of the error.  The JC noted a number of reasons why this might happen.

Common Examples
  • Illegible handwriting on a paper prescription replaced by a mistyped e-script
  • Choosing wrong drug/dose/delivery from a lengthy drop-down list (most recently Westbrook et al, 2013)
  • Filling in prescription on wrong patient (when multiple patient windows can be displayed on a screen)
  • Wrong patient information based on breakdown of patient identifier system
  • Formulary used by prescriber allows substitution (at point of prescribing) when pharmacist may not agree (15% of time) if they saw the original brand name drug prescribed as they do in manual prescribing
  • Outdated medications on medication history
  • Biometric mis-identification
  • Alert blocks necessary treatment (Strom et al, 2010)
  • Changes in Communication Patterns and Practices (Sittig & Ash, 2011)
  • User interface including pick list error or free-text input error (Redwood et al, 2011)
  • Treatment duplication attributed to "signing" versus "administering" (Redwood et al, 2011)
  • Distraction caused by alerts (Redwood et al, 2011)
  • Log-in/log-off status for "signing" (Redwood et al, 2011)
  • Prescribing roles restrictions results in no treatment or unauthorized treatment (Redwood et al, 2011)
  • Enter order on wrong patient's e-chart (can happen on paper - see examples - different reasons) (ISMP MSA 17May11)
  • Changes rather than eliminates errors according to physicians (Lapane, 2011)
  • Actual errors received by a pharmacy (Lockwood, 2012)
  • More coming ...
Quotes

A bit broader than the system generated e-iatrogenesis found on this page ... but nevertheless an interesting read: "e-Pharmacies perpetuate our cultural dependency on drugs and expose us to iatrogenic harm.  ... the primacy of the doctor’s control over health has declined. In its place, a network of nodes participates in medical governance, their global character heralds a departure from parochial conceptions of the doctor–patient relationship." --Nicola Glover-Thomas and John Fanning (article here)

“We’re doing EMR usability at a kindergarten level and some EMR vendors don’t pass that.” --Mark Leavitt - HIMSS Townhall on CCHIT (link)

"HIT that is technically sound at the hardware and software levels may still cause e-iatrogenesis" 
Bernstam et al (2009)

"Vendors avoid liability by relying on the legal doctrine known as “learned intermediaries” and on warranties prohibiting claims against their own products’ fitness. ...  if clinical decision support systems generate incorrect medication dosages because patients’ weights are misconstrued in an internal algorithm (eg, confusing kilograms and pounds), it is the prescriber’s “fault” for not having caught the error." p. 1276 Koppel and Kreda (2009)

"While systems keep historical records of all medications prescribed, active medication lists easily become cluttered with acute, short-term medications and long-outdated medications--potentially resulting in a new cause for medical errors," from article "Physicians Slam E-prescribing Technology Rules"

"We receive e-prescriptions all the time all are perfectly legible...and perfectly illogical. We still have to call the offices just to make sure we don't dispense the wrong thing...arrrgh." Comment on blog post Dr Grumpy in the House.

"The doctors kept on talking about the [order-entry software] itself being a source of errors and stress," recalls sociologist Ross Koppel, lead author of the study, which is published in the Journal of the American Medical Association. "I said, 'No, no, no, this can't possibly be the case, every study shows that it works." But eventually, he had to agree that the residents and interns were right. "Dark Side of Wired Hospitals" Forbes.com

"providers often selected an automated dosage default rather than typing the desired dosage"  ... " many of the errors and issues suggest that standardization through CPOE was not adequately integrated with the workflow, needs, and preferences of the providers"  Singh et al (2009)

16% of electronic prescriptions (weren't they supposed to be error-free?) had internal discrepancies (Palchuk et al, 2010)


References

Aarts, J & Gorman, P 2007, 'IT in Health Care: Sociotechnical Approaches "To Err Is System"', International Journal of Medical Informatics, Vol. 76, no. Supplement 1, pp. S1-S3.


Ash, J.S., Berg, M. & Coiera, E. (2004) 'Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-Related Errors', Journal of American Medical Informatics Association, Vol. 11, No. 2, pp. 104-112.


Bell, DS, Cretin, S, Marken, RS & Landman, AB 2004, 'A Conceptual Framework for Evaluating Outpatient Electronic Prescribing Systems Based on Their Functional Capabilities', Journal of American Medical Informatics Association, Vol. 11, no. 1, pp. 60–70.


Bernstam, EV, Hersh, WR, Sim, I, Eichmann, D, Silverstein, JC, Smith, JW & Becich, MJ 2009, 'Unintended Consequences of Health Information Technology: A Need for Biomedical Informatics', Journal of Biomedical Informatics, Vol. In Press, Corrected Proof.


Borycki, EM, Kushniruk, A, Keay, E, Nicoll, J, Anderson, J & Marilyn, A 2009, 'Toward an Integrated Simulation Approach for Predicting and Preventing Technology-Induced Errors in Healthcare: Implications for Healthcare Decision-Makers', Healthcare Quarterly, Vol. 12, no. Sp, pp. 90-6.


Campbell, EM, Sittig, DF, Ash, JS, Guappone, KP & Dykstra, RH 2006, 'Types of Unintended Consequences Related to Computerized Provider Order Entry', Journal of American Medical Informatics Association, Vol. 13, no. 5, pp. 547-56.


Cohen, H & Shastay, AD 2008, 'Getting to the Root of Medication Errors', Nursing, Vol. 38, no. 12, pp. 39-47.


Chen, Y-F, Neil, KE, Avery, AJ, Dewey, ME & Johnson, C 2005, 'Prescribing Errors and Other Problems Reported by Community Pharmacists', Therapeutics and Clinical Risk Management, Vol. 1, no. 4, pp. 333-42.


Eibling, D 2008, 'Making Us Smart: Why the Design of Clinical Decision Support Systems Is So Critical', The Laryngoscope, Vol. 118, no. 12, pp. 2121-4.


Eslami, S, Abu-Hanna, A, de Keizer, NF & Evert de, J 2006, 'Errors Associated with Applying Decision Support by Suggesting Default Doses for Aminoglycosides', Drug Safety, Vol. 29, no. 9, pp. 803-9.


Glover-Thomas, N & Fanning, J 2010, 'Medicalisation: The Role of E-Pharmacies in Iatrogenic Harm', Medical Law Review, Vol. 18, no. 1, pp. 28-55.


Han, Y.Y., Carcillo, J.A., Venkataraman, S.T., Clark, R.S.B., Watson, R.S., Nguyen, T.C., Bayir, H.l. & Orr, R.A. (2005) 'Unexpected Increased Mortality after Implementation of a Commercially Sold Computerized Physician Order Entry System', Pediatrics, Vol. 116, No. 6, pp. 1506-1512.


Harrison, MI, Koppel, R & Bar-Lev, S 2007, 'Unintended Consequences of Information Technologies in Health Care: An Interactive Sociotechnical Analysis', Journal of the American Medical Informatics Association, Vol. 14, no. 5, pp. 542-9.


Henneman, PL, Fisher, DL, Henneman, EA, Pham, TA, Mei, YY, Talati, R, Nathanson, BH & Roche, J 2008, 'Providers Do Not Verify Patient Identity During Computer Order Entry', Academic Emergency Medicine, Vol. 15, no. 7, pp. 641-8.


Hoff, TJ 2008, 'How Work Context Shapes Physician Approach to Safety and Error', Quality Management in Healthcare, Vol. 17, no. 2, pp. 140-53.


Holden, R 2010, 'Cognitive Performance-Altering Effects of Electronic Medical Records: An Application of the Human Factors Paradigm for Patient Safety', Cognition, Technology & Work, Vol. published on line.


Horsky, J, Zhang, J & Patel, VL 2005, 'To Err Is Not Entirely Human: Complex Technology and User Cognition', Journal of Biomedical Informatics, Vol. 38, no. 4, pp. 264-6.


Kim, G.R., Miller, M.R., Ardolino, M.A., Smith, J.E., Lee, D.C. & Lehmann, C.U. (2007) 'Capture and Classification of Problems During CPOE Deployment in an Academic Pediatric Center',  AMIA Annual Symposium Proceedings.


Koch, S, Gloth, FMM, Nay, R, Koch, S, Forbes, H & Wong, P 2010, 'Common Medication Errors in the Acute Care Sector', in Medication Management in Older Adults, Springer New York, pp. 43-52.


Koppel, R., Metlay, J.P., Cohen, A., Abaluck, B., Localio, A.R., Kimmel, S.E. & Strom, B.L. (2005) 'Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors', JAMA: Journal of the American Medical Association, Vol. 293, No. 10, pp. 1197-1203.


Koppel, R & Kreda, D 2009, 'Health Care Information Technology Vendors' "Hold Harmless" Clause: Implications for Patients and Clinicians', Journal of the American Medical Informatics Association, Vol. 301, no. 12, pp. 1276-8.


Kushniruk, AW, Triola, MM, Borycki, EM, Stein, B & Kannry, JL 2005, 'Technology Induced Error and Usability: The Relationship between Usability Problems and Prescription Errors When Using a Handheld Application', International Journal of Medical Informatics, Vol. 74, no. 7-8, pp. 519-26.


Lapane, K.L., Waring, M.E., Dubé, C.E. & Schneider, K.L. (2011) 'E-Prescribing and Patient Safety: Results from a Mixed Method Study', The American Journal of Pharmacy Benefits, Vol. 3, No. 2, pp. e24-e34.


Lockwood, W. (2012) 'The E-Prescribing Learning Curve: One Pharmacy's Experience', ComputerTalk for the Pharmacist, Vol. 32, No. 1, pp. 15-16.


Nebeker, J.R., Hoffman, J.M., Weir, C.R., Bennett, C.L. & Hurdle, J.F. (2005) 'High Rates of Adverse Drug Events in a Highly Computerized Hospital', Archives of Internal Medicine, Vol. 165.


Palchuk, MB, Fang, EA, Cygielnik, JM, Labreche, M, Shubina, M, Ramelson, HZ, Hamann, C, Broverman, C, Einbinder, JS & Turchin, A 2010, 'An Unintended Consequence of Electronic Prescriptions: Prevalence and Impact of Internal Discrepancies', Journal of the American Medical Informatics Association, Vol. 17, no. 4, pp. 472-6.

Palmieri, PA, Peterson, L & Ford, E 2008, 'Technological Iatrogenesis: New Risks Force Heightened Management Awareness', Journal of Healthcare Risk Management, Vol. 27, no. 4, pp. 19-24.


Palmieri, PA, DeLucia, PR, Peterson, LT, Ott, TE & Green, A 2008, 'The Anatomy and Physiology of Error in Adverse Health Care Events', in GT Savage & EW Ford (eds), Patient Safety and Health Care Management, Vol. 7, pp. 33-68.

Perry, SJ, Wears, RL, Chozos, N & Johnson, C 2008, 'It Came from Within: Clinical Impact of Latent It Failures on Patient Safety', paper presented to HEPS 2008 Scientific Program, Strasbourg, June 25-27.


Reason, J 2004, 'Beyond the Organisational Accident: The Need For "Error Wisdom" On the Frontline', Quality and Safety in Health Care, Vol. 13 no. (suppl 2), p. ii28Yii33.


Redwood, S., Rajakumar, A., Hodson, J. & Coleman, J. (2011) 'Does the Implementation of an Electronic Prescribing System Create Unintended Medication Errors? A Study of the Sociotechnical Context through the Analysis of Reported Medication Incidents', BMC Medical Informatics and Decision Making, Vol. 11, No. 1, p. 29.

Singh, H, Mani, S, Espadas, D, Petersen, N, Franklin, V & Petersen, LA 2009, 'Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order Entry: A Prospective Study', Archives of Internal Medicine, Vol. 169, no. 10, pp. 982-9.


Sittig, DF & Ash, JS 2011, Clinical Information Systems: Overcoming Adverse Consequences, Jones & Bartlett learning.


Strom, BL, Schinnar, R, Aberra, F, Bilker, W, Hennessy, S, Leonard, CE & Pifer, E 2010, 'Unintended Effects of a Computerized Physician Order Entry Nearly Hard-Stop Alert to Prevent a Drug Interaction: A Randomized Controlled Trial', Archives of Internal Medicine, Vol. 170, no. 17, pp. 1578-83.


Wears, RL & Leveson, NG 2008, '“Safeware”: Safety-Critical Computing and Health Care Information Technology', in K Henriksen, J Battles, M Keyes & M Grady (eds), Advances in Patient Safety: New Directions and Alternative Approaches. Vol.4:  Technology and Medication Safety, Agency for Healthcare Research and Quality, Rockville, MD, Vol. 4.


Weiner, JP, Kfuri, T, Chan, K & Fowles, JB 2007, '"E-Iatrogenesis:" The Most Critical Unintended Consequence of CPOE and Other HIT', Journal of the American Medical Informatics Association, Vol. 14, no. 3, pp. 387-8.


Westbrook, J.I., Reckmann, M., Li, L., Runciman, W.B., Burke, R., Lo, C., Baysari, M.T., Braithwaite, J. & Day, R.O. (2012) 'Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital in-Patients: A before and after Study', PLoS Medicine, Vol. 9, No. 1, p. e1001164.


Westbrook, J.I., Baysari, M.T., Li, L., Burke, R., Richardson, K.L. & Day, R.O. (2013online) 'The Safety of Electronic Prescribing: Manifestations, Mechanisms, and Rates of System-Related Errors Associated with Two Commercial Systems in Hospitals', Journal of the American Medical Informatics Association.


Yackel, TR & Embi, PJ 2010, 'Unintended Errors with EHR-Based Result Management: A Case Series', Journal of the American Medical Informatics Association, Vol. 17, no. 1, pp. 104-7.



Additional reference list from AMIA Health Policy Meeting 2009 - Anticipating and Addressing Unintended Consequences of Health Information Technology (HIT) and Policy - September 9-10, 2009  (link to pdf)

See also the related page HCIT Failures

For more on iatrogenesis (without the "e") look at the page on iatrogenesis in geriatic nursing.  One of the suggested remedies is to implement CPOE.  So it seems e-iatrogenesis contributes to cascading iatrogensis especially if the presumption is made that CPOE/EMR has done a check on drug-drug interaction.


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