Duplicate medication orders increased significantly after the implementation of an EHR with CPOE. This occurred despite CDS designed to identify duplicate orders. Our in-depth study of duplicate errors before and after the implementation of CPOE with CDS highlights the remaining vulnerabilities in the system. Duplicate medication errors can increase after CPOE implementation if the multiple factors contributing to the risk of these errors are not anticipated or cannot be remedied before implementation.
CDS is an important feature of health IT. In the future, its effectiveness will depend not only upon the design and implementation of the CDS functionality but also upon consideration of changes to the work system in which it is implemented. The SEIPS model shows us that changing one part of the work system, such as the addition of CPOE, will change all parts of the work system.15
These changes can be predicted before CPOE implementation by using techniques such as proactive risk assessment.18
Once a change is implemented, it is incumbent on the organizations and health IT manufacturers to monitor effects and evaluate the new or persisting hazards. Duplicate medication ordering errors are an example of anticipatable events based on the contributing factors identified in this study. Error recovery systems separate from the CDS systems remain important mechanisms to ensure that medication errors, especially duplicate errors, are caught and do not reach the patient. Heightened physician, nurse, and pharmacist awareness of new errors or unexpected worsening of existing errors after technology implementation is important to ensure that team members remain vigilant for potential ordering errors even though CDS has been implemented to combat the problem.
Our analysis of the contributing factors shows that the causes of most of these duplicate ordering errors were multifactorial (like most other error types). The CPOE design limited the visibility of previously ordered and administered medications, limiting the situation awareness of the ordering providers.20
CPOE and the other components that together comprise the EHR's order-management system must be designed to inform users—at the point of ordering, reviewing, modifying, and administering medications—of the forms and total amount of the medication(s) being ordered that the patient has received and is scheduled to receive. In addition, potentially additive medications (eg, anticoagulants) must be highly visible. The CDS content and interface need to be optimally designed to support the providers in identifying and correcting these duplicate errors.21
Furthermore, the performance of the CPOE manufacturer's duplication-checking algorithms was limited by the design of the medication database. For example, orders for oral and intravenous forms of a medication were not identified as the same medication in the database and therefore were not identified as representing potentially duplicate orders. These false negatives are dangerous to the patient and increase provider distrust of alerts. Additional contributors to error are also important. With the introduction of new information systems, changes in teamwork and communication patterns must be anticipated proactively, monitored, and managed actively. To improve the situation awareness of individual clinicians as well as the team as a whole, any difficulty in accessing and integrating the patient's past, current, and planned future medication use imposed by the order-management system will necessitate more effective communication about order status, particularly around the time of hand-offs.20
Although policies are a relatively weak form of hazard control, clear definition of team roles with regard to order entry is likely to decrease duplication errors.22
For example, rounding teams might designate a single person (physician or pharmacist) to enter medication orders on rounds, with a supervising physician (the attending physician or senior resident) reviewing orders at the conclusion of rounds.
An even more fundamental issue is that organizations make important safety decisions through their purchase and configuration of CPOE. One example of such decisions concerns the design of order sets consistent with evidence-based healthcare and human factors engineering principles. This is an area where substantial research is needed. Order sets can be programmed to have specific orders automatically selected to be ordered when the order set is used. This may decrease the omission of evidence-based interventions (eg, aspirin for patients with an acute heart attack) in patient care but may also be a contributory factor in duplicate medication ordering errors as the provider may have less awareness of what they are ordering. Further research should assess the safety and effectiveness of order set defaults: is it safe and effective that orders are defaulted orders as selected on the order set with the user warned if they are duplicative or potentially additive?23
While we were able to ascertain the frequency of occurrence for some of the contributing factors or duplicate ordering themes, these data do not indicate the importance of the contributing factor; other factors like potential for patient harm and the ability to detect and correct the error before it reaches the patient should also be considered. Moreover, multiple contributing factors likely contribute to each of the duplicate medication order events, thus fixing only one of the factors may not prevent the error from occurring in the future. This study evaluated the design and implementation of a single EHR, yet the persistence or increase in duplicate ordering errors has been noted with other EHRs. However, the CPOE and CDS design issues noted in this study may not be seen with other EHRs.
We propose solutions to mitigate the factors associated with the risk of duplicate medication ordering errors. The solutions conform to the principles of designing systems to (1) support communication and collaboration among the healthcare team, (2) enhance error recovery by improving team and individual situation awareness, particularly around shift changes and other hand-offs, (3) improve teamwork with regards to order entry, and (4) improve the usability and functionality of order entry screens and medication alerts.
- Manufacture medication databases that
- Identify the same medication, regardless of combination, formulation, or route of delivery;
- Identify potentially additive medications regardless of medication class; and
- Identify medication combinations (including doses) that could potentially be additive but have been demonstrated to be safe and effective, for example, the combination of aspirin 81–625 mg once a day with clopidogrel 75 mg a day.
- Manufacture EHR algorithms for checking for potentially duplicate and additive medication orders.
- Apply human factors design principles to make the patient's medication record—both recently administered and planned—more accessible and comprehensible during order planning, entry, review, and administration.
- Apply human factors design principles to create more accessible and comprehensible alerts.
- Select, implement, and maintain health IT products and services for both safety and effectiveness.
- Develop context appropriate policies for order entry. For example:
- Review all recent and planned medications before entering or fulfilling orders.
- Identify one person on a rounding team to enter orders during patient rounds and a supervising physician to review orders immediately after rounds.
- Require hand-offs (for example, at change of shift and patient transfer) to include communication of recent and planned medication orders.
- Review and optimize protocols for care processes likely to create duplicate or additive orders, for example, electrolyte replacement in patients on TPN, anticoagulation, or verbal orders.
To prevent or mitigate an increase in duplicate medication orders will take the concerted efforts of multiple actors including policy makers, medication database manufacturers, EHR manufacturers, healthcare organizations, healthcare teams, and individual clinicians. At the societal level, the availability of safe and effective medication databases and EHRs requires the inclusion of safety into certification requirements and the inclusion of additional software systems (ie, medication databases) into certification schemes. Health IT manufacturers will need to enact the solutions listed above that are relevant to them. Healthcare organizations will need to include the above solutions in their efforts to maximize the benefits and decrease the risks when they implement information technologies.24
Two demonstrated risks of CPOE are particularly relevant to medication safety: increased duplicate errors and alert fatigue.25
The EHR manufacturers must perform usability evaluations of CPOE and design the technology with the contexts of use in mind. Healthcare organizations must work with manufacturers to inform them about those contexts, ensuring that alerts encompass all predictable, relevant situations. Healthcare organizations should provide competency-based EHR training and feedback to users (as well as their supervisors) regarding the frequency of duplicate order entry. Of course, this reporting should not be seen as an adequate substitution for the more effective solutions above. Finally, definitions of healthcare professionalism will need to be extended to include the management of electronic patient information.26