Reducing latent errors, drift errors, and stakeholder dissonance.

Healthcare information technology (HIT) is being offered as a transformer of modern healthcare delivery systems. Some believe that it has the potential to improve patient safety, increase the effectiveness of healthcare delivery, and generate significant cost savings. In other industrial sectors, information technology has dramatically influenced quality and profitability - sometimes for the better and sometimes not. Quality improvement efforts in healthcare delivery have not yet produced the dramatic results obtained in other industrial sectors. This may be that previously successful quality improvement experts do not possess the requisite domain knowledge (clinical experience and expertise). It also appears related to a continuing misconception regarding the origins and meaning of work errors in healthcare delivery. The focus here is on system use errors rather than individual user errors. System use errors originate in both the development and the deployment of technology. Not recognizing stakeholders and their conflicting needs, wants, and desires (NWDs) may lead to stakeholder dissonance. Mistakes translating stakeholder NWDs into development or deployment requirements may lead to latent errors. Mistakes translating requirements into specifications may lead to drift errors. At the sharp end, workers encounter system use errors or, recognizing the risk, expend extensive and unanticipated resources to avoid them.