This paper summarizes the foci, activities, methods, and results of a three-year research project. Using a mixed methods approach, the Physician Order Entry Team has identified and categorized the unintended consequences of computerized physician order entry (CPOE). After analyzing 380 examples of unintended adverse consequences, the team described in detail nine major types and conducted a national survey in the U.S. to discover how hospitals recognize and deal with unintended consequences. With the assistance of a panel of experts, the team identified strategies for managing unintended adverse consequences and outlined contents of a toolkit for CPOE implementers for addressing them.
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