| Factors contributing to an increase in duplicate medication order errors after CPOE implementation. | |
| | |
MedLine Citation:
|
PMID: 21803925 Owner: NLM Status: Publisher |
Abstract/OtherAbstract:
|
Objective To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors. Design CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs). Measurement Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors. Results Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered. Conclusions Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence. |
| | |
Authors:
|
Tosha B Wetterneck; James M Walker; Mary Ann Blosky; Randi S Cartmill; Peter Hoonakker; Mark A Johnson; Evan Norfolk; Pascale Carayon |
Related Documents
:
|
9777485 - Medical genetic evaluation for the etiology of hearing loss in children. 19163765 - Assessment of the effects of subthalamic stimulation in parkinson disease patients by a... 15460675 - Usability assessment study of a web site displaying medical resources on line: the cismef. 10255455 - Federal old-age, survivors, and disability insurance; revised medical criteria for the ... 18997355 - Medical professionalism: one size fits all? 8336575 - Rural doctor recruitment: does medical education in rural districts recruit doctors to ... |
Publication Detail:
|
Type: JOURNAL ARTICLE Date: 2011-7-29 |
Journal Detail:
|
Title: Journal of the American Medical Informatics Association : JAMIA Volume: - ISSN: 1527-974X ISO Abbreviation: - Publication Date: 2011 Jul |
Date Detail:
|
Created Date: 2011-8-1 Completed Date: - Revised Date: - |
Medline Journal Info:
|
Nlm Unique ID: 9430800 Medline TA: J Am Med Inform Assoc Country: - |
Other Details:
|
Languages: ENG Pagination: - Citation Subset: - |
Affiliation:
|
Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA. |
Export Citation:
|
APA/MLA Format Download EndNote Download BibTex |
| MeSH Terms | |
Descriptor/Qualifier:
|
|
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
Previous Document: Evaluation of a prototype interactive consent program for pediatric clinical trials: a pilot study.
Next Document: Standards for reporting randomized controlled trials in medical informatics: a systematic review of ...