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

This is the reviews for S. Magid, C. Forrer, and S. Shaha’s 2012 article for Duplicate Orders: An Unintended Consequence of Computerized Provider/Physician Order Entry (CPOE) Implementation: Analysis and Mitigation Strategies.

Background

A Computerized Physician Order Entry (CPOE) is meant to improve order efficiency and patient safety but sometimes, just like any new technology, there can be unintended consequences. 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.For more information,please visit AHRQ site: [1] In this study, the author identifies the causes of duplicate orders and describes how and what they did to reduce these duplicates.

Method

The study took place within an 84-week time frame and was at Hospital for Special Surgery in New York City. For the study, they looked at different variables such as the following:

• Drug (Which medication was duplicated the most)
• Prescriber (Was the duplication from the same provider or did two different providers write for the same medication?)
• Department (Was the duplication from the same department or in different departments such as one prescribed in radiology and the other in pediatrics)
• Prescriber Group – Which group accounted for the most duplications (Neurology, Pediatrics, etc..)
• Type of order (Did Order Sets caused more duplications or Individual Orders)
• Workflow (When a patient gets transferred to another unit or pavilion, are duplications more likely to occur?)

Findings / Results

The study was very successful in determining the root causes of the order duplications. Since they were able to pinpoint the causes, they were able to take different measures in reducing the amount of duplications at the hospital. Some examples include:

• Eliminating certain drugs from an order set
• “Un-defaulting” certain medications from an order set
• Activating alerts, e-mail notifications, and reminders
• Additional training: Individual, Departmental, and CD & computer based
• Department emails, meetings, and lectures

Overall, these strategies were able to greatly decrease the number of duplicate orders.

The following is a graph showing the dramatic difference in pre- and post-intervention: [2]

Comments

It is interesting to see the huge decrease in duplications after the interventions. According to this study, order sets were associated with the most duplication. I find this a bit surprising because the CPOE/EHR that I have worked with has the ability to alert the end user of any overlapping order sets. Training, meetings, and emails are great ways to re-educate the staff. Ever so often, end users should be trained again so that they know the proper way to use the system and also learn about any new updates. Another interesting article to review this information is from Today's Hospitalist([3])