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The focus on quality improvement has led to several types of initiatives in pediatric care; however, these programs may lead to potential unintended consequences.Unintended consequences of quality improvement programs that have been described are reviewed. Unintended effects on resource utilization include effects on costs, as well as the inability to apply programs across different populations and affect disparities in care. Unintended effects on provider behavior include measurement fixation behavior, as well as ‘crowding out’ behavior, in which gains in quality in one area may simply occur at the expense of quality of care in another. Patient preferences may not always match specific quality improvement measures. Unintended effects for patients may include decreased patient satisfaction, trust, or confidence in their provider.Recognition and anticipation of the possible unintended consequences of guideline implementation is a critical step to harnessing all the benefits of quality improvement in practice.