Table 3.
Order set items with the highest and lowest risks of order retraction relative to when the same items were ordered a la carte, excluding uncommon order sets used fewer than 100 times
| (a) Order set items with the highest risk of retraction relative to a la carte | ||||||
| Order set | Item | Retraction count (order set) |
Retraction rate
(order set) (%) |
Retraction count
(a la carte) |
Retraction rate
(a la carte) (%) |
Retraction relative risk |
| Vascular ICU | Esmolol IV | 3 | 38 | 1 | 0.9 | 42.8 |
| Neurology general ward admit | Atorvastatin PO | 2 | 40 | 60 | 1.6 | 25.0 |
| ED abdominal pain | Pantoprazole IV | 2 | 100 | 688 | 5.3 | 18.8 |
| Nursing triage pain management protocol | Ondansetron PO | 2 | 67 | 153 | 3.6 | 18.6 |
| NSTEMI admit | Atorvastatin PO | 3 | 33 | 96 | 1.9 | 17.8 |
| Pneumonia | Ceftriaxone IV | 3 | 75 | 13 | 4.8 | 15.7 |
| Medicine general admit | Warfarin PO | 5 | 38 | 96 | 1.9 | 15.3 |
| ICU surgery/trauma admit | Pantoprazole PO | 5 | 23 | 624 | 2 | 11.6 |
| Lung, heart–lung transplant post op | Piperacillin–tazobactam IV | 3 | 60 | 466 | 5.6 | 10.6 |
| Cardiac surgery admission | Polyethylene glycol | 7 | 41 | 89 | 4 | 10.4 |
| (b) Order set items with lowest risk of retraction relative to a la carte | ||||||
| Order set | Item | Retraction count (order set) |
Retraction rate
(order set) (%) |
Retraction count
(a la carte) |
Retraction rate
(a la carte) (%) |
Retraction relative risk |
| Bronchoscopy | Lidocaine injection | 5 | 0.5 | 2 | 40.0 | 0.01 |
| Haemodialysis | Heparin injection | 2 | 0.2 | 164 | 5.7 | 0.04 |
| Joint replacement | Normal saline IV bolus | 3 | 0.1 | 2225 | 2.7 | 0.04 |
| Haemodialysis | Mannitol IV | 6 | 2.0 | 21 | 32.8 | 0.06 |
| Bowel resection post op | Lidocaine injection | 2 | 0.3 | 132 | 4.6 | 0.06 |
| Comfort care | Glycopyrrolate IV | 2 | 0.5 | 61 | 5.9 | 0.08 |
| Neurosurgery post op | Lidocaine injection | 6 | 0.3 | 457 | 4.1 | 0.08 |
| Haemodialysis | Lidocaine injection | 3 | 0.3 | 457 | 4.1 | 0.08 |
| Head and neck post op | Morphine injection | 4 | 0.5 | 61 | 6.1 | 0.08 |
| Neurosurgery post op | Potassium chloride liquid PO | 3 | 0.4 | 425 | 5.3 | 0.08 |
The retraction relative risk=(retraction rate from order set)/(retraction rate a la carte). Items in 3a represent those that are particularly poorly aligned with clinician workflow given how much more likely they are ordered in error from the corresponding order set, while items in 3b appear to be particularly well aligned.
ED, emergency department; ICU, intensive care unit; IV, intravenous; NSTEMI, non-ST elevation myocardial infarction; PO, by mouth.