Duplicate medication order errors increase after computerized provider order entry is implemented

Research Activities, January 2012, No. 377

Electronic health records that include computerized provider order entry (CPOE) with clinical decision support (CDS) have been shown to improve areas of patient safety, such as reducing duplicate orders and other medication errors. However, some studies have noted continuing or even increasing medication errors even after implementation of CPOE. A new study found that factors contributing to an increase in duplicate medication order errors after CPOE implementation were related to the CPOE technology and/or CDS design, organizational factors, user practices, tasks, and the environment.

The study focused on the implementation of CPOE with duplicate medication order alerts in a 400-bed hospital. Through chart reviews, computer-generated reports, provider alerts, and staff reports, the researchers were able to identify an increase in duplicate orders in two intensive care units, from 1.16 errors/100 patient-days pre-implementation to 4.16 errors/100 patient-days post-implementation.

Most of the orders involved identical orders or same-medication orders. Several contributing factors were identified. On hospital rounds, two orders were often placed within minutes by different members of the rounding team, who were unaware of each other's activity. Shift changes were also associated with duplicate orders. Information-display issues, included confusing alerts and difficulty reviewing existing orders, were also associated with duplicate orders.

The researchers offer eight approaches to reducing duplicate medication ordering errors. All of them relate to supporting communication and teamwork among CPOE users or to improving usability and functionality of CPOE systems. The study was supported in part by the Agency for Healthcare Research and Quality (HS15274 and HS17014).

See "Factors contributing to an increase in duplicate medication order errors after CPOE implementation," by Tosha B. Wetterneck, M.D., James M. Walker, M.D., Mary Ann Blosky, M.S., R.N., and others in the Journal of the American Medical Informatics Association 18, pp. 774-782, 2011.

Current as of January 2012
Internet Citation: Duplicate medication order errors increase after computerized provider order entry is implemented: Research Activities, January 2012, No. 377. January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsletters/research-activities/jan12/0112RA12.html