Table 2.

Contributing factors associated with duplicate ordering errors after CPOE/CDS implementation and proposed solutions

Work system category(ies)	Contributing factor	Contributing factor details	Frequency of occurrence and examples	Proposed solutions
Technology: CDS duplicate alerts	Alert design interface (content and layout) is inadequate for error detection and correction needs.*	All CDS alerts display on one screen as rows of text. Users are neutral about the usefulness of duplicate alarms.	See figure 1	Present alerts to users sequentially. Clearly separate alerts by type (eg, duplicate, drug interaction). Add information on the severity of the alert so the user can prioritize their actions.
Technology: CDS duplicate alerts and People: Individual Providers and Healthcare organization	High false-positive rate of duplicate alerts leads to frequent overrides, sometimes without reading the alert.*	Users will learn to ignore alarms with high false-positive rates. Majority of duplicate ordering errors had overridden alerts. Time pressure and workload in ICU setting Unclear organizational audit and feedback to users regarding inappropriately overridden alerts.		Work on sensitivity and specificity of alerts with manufacturers. Customize alerts at the individual alert level. Develop potentially additive medication alerts to improve positive predictive value of same therapeutic class alerts. Maintain pharmacist error recovery role. Train clinicians to recognize importance of CDS alerts for error detection and correction. Audit the percent of alerts that are overridden and the percent that are incorrectly overridden and provide feedback to users.
Technology: CDS duplicate alerts and medication database design	Current CDS algorithms miss important duplicates.	New orders are not checked against recently completed (administered) orders. The same medications administered by different routes are treated as the same.	24 Occurrences (14% of duplicate order errors) KCl 20 meq IV once ordered at 06:00 h, administered at 06:30 h. New order for KCl 20 meq at 07:30 h by different physician not identified as a duplicate Same medication with different route, for example, metoprolol 25 mg p.o. and metoprolol 5 mg IV	Ensure duplicate algorithms check recently completed orders. Have medication database manufacturer store and process the medication and route separately.
Technology: CPOE design	Difficulty reviewing existing medication orders at the time of ordering.*	Current and recently administered orders are not visible on the computer screen while ordering medications.	During a procedure a provider gives a verbal order for sedation. The nurse enters that order as does the provider 15 min later (5 verbal order occurrences, 3% of duplicate order errors) Provider enters the same order as another provider 1–10 min apart on rounds (17 occurrences, 10% of duplicate order errors)	Make ‘verbal orders to sign’ highly visible and part of workflow before entering new orders. Make recent medication orders more visible to the provider at the time of ordering.
Technology: CPOE design	More than one person can access the ordering screen and write orders for a patient at the same time.*	Strategic decision to allow multiple users to access the same patient chart at once. CPOE system does not prevent two users from entering orders at the same time.		Believe benefit of more than one provider accessing the same patient chart outweighs risk, so address/reduce risk via other means (eg, see below). Modify CPOE such that if two users are in the ordering screens at the same time, after the first set of orders are signed off, those orders are presented to the second user prior to signing of additional orders.
Technology: CPOE design	Orders placed within the same ordering session not readily visible to the provider.	Same provider orders the same medication twice during the same ordering session.	11 Occurrences, 7% of duplicate order errors	List medication orders from given order session on screen at all times while entering orders.
Technology: CPOE design	CPOE does not allow linkage of orders in the medication administration record such that the nurse can administer one or the other.	Postoperative order set includes order for medication via IV route and oral route; both are checked by user with expectation that nurse will implement the appropriate order based on the patient's condition.	4 Occurrences, 2% of duplicate order errors. Pre-CPOE order sets had orders such as, ‘Pepcid 20 mg IV every 12 h, change to p.o. when taking p.o.’	Add CPOE logic for linking orders, including if–then orders. Improve team communication.
Technology: CPOE design	Need to cancel existing order and enter a new order to change the route of an existing order.	Provider can change the dose and frequency of existing orders but must cancel and reorder a medication to change the route.	Provider enters order for metoprolol 50 mg p.o. twice daily and there is an existing order for metoprolol 5 mg IV every 6 h that is not discontinued (and a duplicate alert does not fire—see above).	Have manufacturer change configuration of medication database such that the medication and route are not linked as the medication product so changes in route can be accomplished by modifying an existing order.
Healthcare organization	Order sets designed with pre-checked orders (defaults) to speed ordering process for users.	Provider uses two similar order sets to admit the patient, each has the same order ‘pre-checked’ to order.	13 Occurrences, 8% of duplicate order errors. Patient comes from catheterization (cath) lab to cardiac ICU and provider uses ‘post-cath’ and ‘cardiac ICU admission’ order sets, both of which have clopidogrel defaulted as ordered on them	Combine order sets commonly used together into one order set and thus eliminate duplicate orders. Develop ‘smart’ order sets that can identify if an order already exists for a medication on the order set and inform the user at the time of ordering.
Healthcare organization and Environment	Team structure/role definitions may not be well defined with regard to who is team order writer, especially during rounds; lack of communication about medication ordering on rounds. Layout and accessibility of computers easily allows more than one user to write an order for a patient within same time period.	The identical order placed by two different team members (attending or resident physician, physician assistant, or pharmacist) within 1–10 min during ICU rounds. Workstations on wheels (WOWs) and computers readily available (there was only one paper chart). Rounds are often done in a circle of people with WOWs so everyone can access and use the same data on the EHR system.	17 Occurrences, 10% (identical orders during rounds). See table 1 for additional order timing data.	Define team roles during rounds and responsibility for order entry and order entry supervision. Improve communication among team members to improve team awareness about who is entering orders, what is entered, and when. Believe benefits outweigh risk for environmental causes; reduce risk via other means.
People: individual providers	Change in medication therapy within therapeutic class but previous order is not discontinued.		Provider changes therapy between proton-pump inhibitor and H2 blocker, heparin, and low-molecular weight heparin, or antibiotics and does not cancel previous therapy order (nine occurrences, 5%).	Improve the content and specificity of same therapeutic class duplicate alerts.
Task: ordering practices and People: teamwork	Hand-offs do not include information about routine (mundane) events, for example, electrolyte replacement.*	Labs drawn early morning in ICU, overnight person commonly called to replace electrolytes.	For example, KCl 20 meq IV once ordered at 06:00 h. Dayshift comes on at 07:00 h, reviews labs and writes order for KCl 20 eq at 07:30 h.	Include details on patient orders written overnight in hand-off communication. Act only on critical lab results overnight, save morning lab review and actions for day-shift provider.

^*Unable to reliably determine frequency of occurrence.

CDS, clinical decision support; CPOE, computerized provider order entry.