Reducing Therapeutic Duplication in Inpatient Medication Orders.

Area of Science:

• * Health Informatics
• * Clinical Pharmacy
• * Patient Safety

Background:

• * Therapeutic duplication, prescribing multiple medications for the same condition without clear usage instructions, poses a significant risk for medical errors.
• * Joint Commission standards mandate clarity in medication orders to prevent such errors.
• * In pediatric settings, as needed (PRN) acetaminophen and ibuprofen orders are identified as major contributors to therapeutic duplication.

Purpose of the Study:

• * To design and evaluate the effectiveness of clinical decision support (CDS) interventions aimed at reducing therapeutic duplication of acetaminophen and ibuprofen.
• * To compare the impact of interruptive alerts versus discrete PRN reasons on medication order clarity and duplication rates.

Main Methods:

• * A pediatric health system with three hospitals implemented two iterative CDS strategies.
• * Strategy 1 involved interruptive alerts at order entry to prompt clarifying PRN comments.
• * Strategy 2 added discrete "first-line" and "second-line" PRN reasons to orders.
• * Therapeutic duplications were quantified through manual order review over 30-day periods before and after each intervention, and six months later.

Main Results:

• * Initial interruptive alerts reduced therapeutic duplications from 1,485 to 818, but rates increased to 1,208 before the second intervention.
• * Following the addition of discrete PRN reasons, therapeutic duplications dropped to 336 and remained low at 277 six months later.
• * Alert fatigue was noted, with interruptive alert rates decreasing from 76.0 to 42.9 per 1,000 PRN orders after the second intervention.

Conclusions:

• * While interruptive alerts can decrease therapeutic duplication, they are linked to user frustration and alert fatigue.
• * Employing discrete PRN reasons for "first-line" and "second-line" use proved more effective in reducing therapeutic duplication.
• * This approach also resulted in fewer interruptive alerts and reduced manual data entry for healthcare providers.