Some unanticipated consequences of the implementation of a hospital IT system: learning from a case study

Technology offers potentially attractive solutions to patient safety concerns. Evidence is accumulating that

errors can be reduced and practitioner performance improved through the implementation of computerised

prescribing systems (CPS), but few interventions are free of unanticipated consequences. The aims of this

session are to: share the learning from a case study of a large acute hospital in the UK with a sophisticated

CPS; explain how unanticipated consequences arise in the sociotechnical system, illustrate these with

examples, both beneficial and potentially harmful, and identify how they affect patient safety; emphasise the

importance of being vigilant to the effects on patient safety when new technology mixes with long

established work patterns; and invite comment and discussion about how health care organisations can

harness beneficial effects and mitigate potential harm.