Factors contributing to an increase in duplicate medication order errors after CPOE implementation

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Factors contributing to an increase in duplicate medication order errors after CPOE implementation : [1].


The implementation of CPOE/ CDS is extremely beneficial in simplifying and optimizing the Order Management System (OMS), streamlining physicians’ and nurses’ workflows, minimizing medication errors and improving healthcare delivery. However, the implementation has to be planned and executed carefully to avoid issues that might arise out of inadequate planning, lack of attention to integration with existing workflows or other unintended consequences


The objective of the study was to study the incidence of duplicate medication orders before and after the implementation of a CPOE/ CDS system and to study contributory factors for the same.


The authors carried out a prospective pre and post implementation study in a 400-bed Northeastern US community tertiary care teaching hospital and used chart reviews, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors and their causes,in two intensive care units (ICUs) [1].


Data were collected on 630 patients, 45 658 medication orders, and 4147 patient-days pre-CPOE, and 625 patients, 32 841 medication orders, and 4013 patient-days post-CPOE. The number of duplicate medication orders increased after CPOE implementation (pre: 48 errors, 1.16 errors/100 patient-days; post: 167 errors, 4.16 errors/100 patient-days; p<0.0001) [1].

Causative Factors

  • 1. Number of providers involved in care of patient and entry of orders.

Due to various causes including lack of visibility of previous doctor’s orders, involvement of multiple caregivers creating orders and alert fatigue and overriding of orders.

  • 2. Inadequate duplicate alert algorithms and design

Lack of detection of duplicate orders due to passage of an interval of time between orders, different routes of administration etc.

  • 3. Duplicate alert design and physician perception of usefulness of alerts

Multiple false positive alerts lead to alert fatigue among physicians leading to the masking of the true positive alert.


As seen in this study, implementation of EMR systems like CPOE and CDS requires a robust change management plan. Training and gradual implementation is important as well as continuous improvement activities catering to the adoption and customization of the technology in the physicians and nurses’ workflows. Usability , teamwork and communication between stakeholders is essential

Related Read: Duplicate orders: an unintended consequence of computerized provider/physician order entry (CPOE) implementation: analysis and mitigation strategies


  1. 1.0 1.1 1.2 Wetterneck, T. B., Walker, J. M., Blosky, M. A., Cartmill, R. S., Hoonakker, P., Johnson, M. A., … Carayon, P. (2011). Factors contributing to an increase in duplicate medication order errors after CPOE implementation. Journal of the American Medical Informatics Association : JAMIA, 18(6), 774–782. doi:10.1136/amiajnl-2011-000255. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198002/?tool=pmcentrez