ABSTRACT
Information technology (IT) has repeatedly demonstrated its capacity to improve the safety and quality of healthcare. It does this by shaping the information that is collected or seen at the time of decision-making or using that information to automate clinical processes. Indeed, there is probably no more foundational way of intervening in the practice and delivery of healthcare than to alter its informational and decision substrate. When the consequences of such an intervention are as intended, then we have a powerful tool to alter practice for the good. When it goes awry, there are unintended consequences, and these may distort information, misguide decisions or trigger actions that can lead to harm to a patient (Ash et al., 2004). Recall from Chapter 1 how errors in the design of the software and hardware of the Therac-25 radiotherapy machine harmed multiple patients, some of whom died as a result of radiation overdoses (see Box 1.1).
