Factors contributing to an increase in duplicate medication order errors after CPOE implementation.

Area of Science:

• Health Informatics
• Patient Safety
• Medication Error Research

Background:

• Duplicate medication orders pose a risk to patient safety.
• Implementing advanced systems like CPOE with CDS aims to reduce errors.

Purpose of the Study:

• To assess the incidence of duplicate medication orders before and after CPOE with CDS implementation.
• To identify factors contributing to duplicate medication ordering errors.

Main Methods:

• A pre-post implementation study design was used in two ICUs of a tertiary care hospital.
• Trained nurses collected data through chart review and system reports.
• Physicians and human factors engineers adjudicated errors, with qualitative analysis for contributing factors.

Main Results:

• Duplicate medication ordering errors significantly increased post-CPOE implementation (2.6% to 8.1%).
• Common duplicates included identical orders or the same medication.
• Contributing factors involved provider practices, communication issues, CDS alert design, and CPOE data display.

Conclusions:

• CPOE with CDS implementation led to an increase in duplicate medication order errors.
• Work system factors, including CPOE, CDS, and database design, were significant contributors.