Redundant medication orders occurred more often with computerized physician order entry and clinical decision support systems than without.
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Computerized physician order entry (CPOE), backed with clinical decision support (CDS), has long been considered an essential component of an electronic health record (EHR) because it is supposed to decrease duplication of orders and help prevent medical errors. But a new study suggests that some CPOE systems could be having exactly the opposite effect.
"Duplicate medication orders increased significantly after the implementation of an EHR with CPOE. This occurred despite CDS designed to identify duplicate orders," researchers from the University of Wisconsin-Madison and Geisinger Health System in Pennsylvania reported in an article published in the Journal of the American Medical Informatics Association (JAMIA).
After studying two intensive care units (ICUs) at a 400-bed rural teaching hospital in the Northeast--a standard, adult ICU and a cardiac ICU, each with similar ordering processes--before and after CPOE implementation in 2007, the research team found a higher rate of duplication with the technology in place. Identical orders jumped from 0.36 to 1.72 incidents per 100 patient days, while same-medication errors increased from 0.31 to 1.87 per 100 patient days. They also found a slight uptick in the rate of orders of medications in the same therapeutic class.
Among the contributing factors:
-- two orders were sometimes placed within minutes by different providers on rounds;
-- duplicate orders were given during shift changes; and
-- the CDS and medication database were poorly designed. In some cases, this resulted in high false-positive alert rates; at other times the CDS algorithms overlooked true duplicates.
The authors were particularly concerned with physicians ignoring or overriding alerts and with communication problems during patient handoffs. According to the study, 43% of duplicate orders were placed within an hour of each other by different providers, though 7% came from the same provider during a single-order session, meaning that they overrode alerts warning them that they were entering the same order more than once.
Digging a little deeper in the mistakes, the investigators found that "the performance of the CPOE manufacturer's duplication-checking algorithms was limited by the design of the medication database." They discovered, for instance, that the database didn't recognize oral and intravenous forms of a medication as the same drug in the database.
The remedy must be multifaceted, according to the study, which was funded by grants from the U.S. Agency for Healthcare Research and Quality and the National Center for Research Resources, part of the National Institutes of Health. Healthcare providers should concentrate on medication databases and EHR algorithms that can identify potential duplications, better alert design, improved communication at patient handoff, and optimization of care protocols that could prevent duplication or "additive" orders, the research team said.
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