Computerized physician order entry (CPOE) has had demonstrated benefits in error reduction and guideline adherence, but its implementation has often been complicated by disruptions in established workflow processes. The following study of a healthcare team in an intensive care unit after the implementation of mandatory CPOE found that policies designed to increase flexibility and safety led to an increased coordination load on the healthcare team, and created opportunities for new sources of error. Observational workflow studies are an important tool to understand how to redesign CPOE systems so as to avoid harm and achieve the full potential of benefit for improved patient safety.