Table 1.

Orders and Actions by Providers A and B over Two Days

Time	Provider	Action	Type	Description	Notes/Findings	Order No.
Saturday 13:30 7 min	A	ACT	IV injection	40 mEq KCl IV injection over 4 hr	Correct order	1
				Decision	Provider wants to change IV injection of KCl to a medicated drip to avoid pain on administration
		DC	Drip	D5W nonmedicated fluid	Discontinues an older standing order (not in table)	2
		ACT	Drip	D5W with 40 mEq KCl 1,000 mL @ 75 mL/hr	Intended for 1 L of fluid only; free-text volume limit, auto stop in 7 days	3
		DC	Drip	Preceding order discontinued	Realizes the preceding order [3] was incorrect and discontinues it	4
		ACT	Drip	D5W nonmedicated fluid	Enters order identical to the one just discontinued [2]	5
		ACT	Drip	D5W with 100 mEq KCl 1,000 mL @ 75 mL/hr	Second attempt to enter drip order, similar to order [3]; now with a higher dose (100 mEq)	6
		DC	IV injection	KCl 20 mEq	Meant to discontinue order [1] but discontinued an expired order from 2 days before (not in table)	7
		49-min time lag			Pharmacy calls to warn about order [6], which has dose over limit (100 mEq, max. allowed 80 mEq)
Saturday 14:26 16 min	A	DC	Drip	D5W nonmedicated fluid	Discontinues nonmedicated fluid order [5] in response to the call from pharmacy	8
		DC	Drip	D5W with 100 mEq KCl 1,000 mL @ 75 mL/hr	Discontinues erroneous drip order [6] in response to the call from pharmacy	9
		ACT	Drip	D5W with 80 mEq KCl 1,000 mL @ 75 mL/hr	Enters recommended 80 mEq. Intended for 1 L only, but no stop time entered; auto stop in 7 days	10
		52-min time lag
Saturday 15:34	A	DC	Drip	D5W with 80 mEq KCl 1,000 mL @ 75 mL/hr	The preceding order [10] discontinued	11
		ACT	Drip	D5W with 80 mEq KCl 1,000 mL @ 75 mL/hr	The same order [cf. 10, 11] re-entered, runs for 36 hr and delivers 216 mEq KCl	12
		27-hr time lag
		Change of providers
Sunday 18:36	B	ACT	IV Injection	40 mEq KCl IV injection	Misperceived older potassium laboratory values as current; did not notice a running KCl drip [12]	13
		34-min time lag
Sunday 19:10	B	DC	IV Injection	40 mEq KCl IV injection	The preceding order [13] discontinued	14
		ACT	IV Injection	60 mEq KCl IV injection	Increased IV injection dose to 60 mEq	15
		27-min time lag
Sunday 19:37	B	ACT	IV Injection	40 mEq KCl IV injection	Another IV injection of KCl ordered; however, no clear evidence that it was in fact administered	16

ACT = activate; DC = discontinue; IV = intravenous.