Duplicate Medication Orders after CPOE Implementation

1University of Wisconsin School of Medicine and Public Health, Madison, Wl
2University of Wisconsin, Madison, Wl
3Geisinger Health System, Danville, PA
4University of Wisconsin, Madison, Wl

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 151


Computer provider order entny (CPOE) systems with clinical decision support can alert providers to medication ordering errors such as duplicate medication orders. Yet many ordering errors persist despite these interventions. Duplicate orders after CPOE implementation are analyzed to determine why these errors may persist despite decision support.


CPOE was implemented in a 400‐bed community tertiary‐care teaching hospital in the northeastern United States. The CPOE had built‐in duplicate alerts for duplicate medication orders based on medication name and class which were presented to providers at the time of signing orders and could be overridden. The study was performed in 2 intensive care units (ICUs), a 24‐bed adult critical care ICU serving trauma and an 18‐bed cardiac ICU. Error and adverse drug event (ADE) data were collected per protocol 3 months after implementation by trained nurses using electronic chart review, computer generated reports of medication orders and alerts to providers, and staff report. When a medication error was noted, standard data were collected that represented a medication event. Events were adjudicated by a physician and a human factors engineer to determine whether a medication error occurred and the stage and type of error. Duplicate medication orders were considered errors only if the provider overrode a correct duplicate alert, were intervened an by pharmacy or nursing, or led to patient harm. Duplicate orders for which providers received alerts and changed the order were not considered errors as this was the purpose of the CDS, and the order was actually never implemented in the computer system.


Data were collected on 644 patients over 4 months representing 4139 patient‐days. The combined average ICU length of stay was 6.5 ± 8.2 days. Preliminary data analyses revealed 1829 events with 1 or more medication errors or ADEs and 155 duplicate medication ordering errors. The same medication order accounted for the duplicate order in 67 events, 68 events had the same medication but different dose, frequency, or route, and 20 were duplicates in the same medication class. Many of the same medication and same order duplicate errors were placed within minutes of each other by different providers; some evert by the same user within the same ordering session. Same medication order errors were also common around morning change of shift for electrolyte replacement, often without duplicate alerts firing as the first order had been implemented. Same‐class duplicate errors tended to be new orders for a change in therapy in which the previous therapy was not canceled or new orders for therapy that were already being implemented in total parenteraI nutrition orders for the day.


Duplicate medication errors persist despite CPOE implementation with CDS. Understanding these errors may help in the design of better CDS and systems to prevent their occurrence.

Author Disclosure:

T. Wettemeck, none; Randi Cartmill, none; James Walker, none; Pascale Carayon, none.

To cite this abstract:

Wettemeck T, Cartmill R, Walker J, Carayon P. Duplicate Medication Orders after CPOE Implementation. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 151. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/duplicate-medication-orders-after-cpoe-implementation/. Accessed April 6, 2020.

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