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.