Duplicate orders: an unintended consequence of computerized provider/physician order entry (CPOE) implementation: analysis and mitigation strategies
This is the reviews for S. Magid, C. Forrer, and S. Shaha’s 2012 article for Duplicate Orders: An Unintended Consequence of Computerized Provider/Physician Order Entry (CPOE) Implementation: Analysis and Mitigation Strategies.
A Computerized Physician Order Entry (CPOE) is meant to improve order efficiency and patient safety but sometimes, just like any new technology, there can be unintended consequences. A new study found that factors contributing to an increase in duplicate medication order errors after CPOE implementation were related to the CPOE technology and/or CDS design, organizational factors, user practices, tasks, and the environment.For more information,please visit AHRQ site:  In this study, the author identifies the causes of duplicate orders and describes how and what they did to reduce these duplicates.
The study took place within an 84-week time frame and was at Hospital for Special Surgery in New York City. For the study, they looked at different variables such as the following:
- Drug (Which medication was duplicated the most)
- Prescriber (Was the duplication from the same provider or did two different providers write for the same medication?)
- Department (Was the duplication from the same department or in different departments such as one prescribed in radiology and the other in pediatrics)
- Prescriber Group – Which group accounted for the most duplications (Neurology, Pediatrics, etc..)
- Type of order (Did Order Sets caused more duplications or Individual Orders)
- Workflow (When a patient gets transferred to another unit or pavilion, are duplications more likely to occur?)
Findings / Results
The study was very successful in determining the root causes of the order duplications. Since they were able to pinpoint the causes, they were able to take different measures in reducing the amount of duplications at the hospital. Some examples include:
- Eliminating certain drugs from an order set
- “Un-defaulting” certain medications from an order set
- Activating alerts, e-mail notifications, and reminders
- Additional training: Individual, Departmental, and CD & computer based
- Department emails, meetings, and lectures
Overall, these strategies were able to greatly decrease the number of duplicate orders. 
The following is a graph showing the dramatic difference in pre- and post-intervention: 
It is interesting to see the huge decrease in duplications after the interventions. According to this study, order sets were associated with the most duplication. I find this a bit surprising because the CPOE/EHR that I have worked with has the ability to alert the end user of any overlapping order sets. Training, meetings, and emails are great ways to re-educate the staff. Ever so often, end users should be trained again so that they know the proper way to use the system and also learn about any new updates. Another interesting article to review this information is from Today's Hospitalist()
This is a review of Magid, Forrer, and Shaha’s 2012 article, Duplicate Orders: An Unintended Consequence of Computerized provider/physician order entry (CPOE) Implementation: Analysis and Mitigation Strategies 
The benefits of computerized provider/physician order (CPOE) entry - particularly with clinical decision support (CDS) - has been shown to increase patient safety. CPOE has also been reported to improve:
- The utilization of health care services
- Decrease costs
- Reduce hospital length of stay
- Decrease medical errors
- Improve compliance with guidelines
The authors’ objective in this report was to describe the nature of duplicate orders, report their analysis of them and describe the methods used to reduce them.
Duplicate medication orders (“duplicates”) were defined for the study as two or more active orders for the identical medication regardless of dose. The second order entered was labeled as the duplicate order. Certain orders were not considered to be duplicates and were excluded from analysis. These include:
- Dose range ordering (e.g. acetaminophen: one pill for mild pain and two pills for severe pain)
- Combination drug plus component (e.g. losartan/HCTZ plus HCTZ or Percocet plus acetaminophen)
- The same drug prescribed for different indications (e.g. acetaminophen for pain and acetaminophen for fever)
- Large volume parenterals
A total of 316,160 orders were captured during the 84 weeks, averaging 3,764 orders per weekly sampling period.
- There were 5,442 duplicate orders over this period, an average duplication rate of 1.8%.
- The highest rate was 5.0% (211/4,220) in week 1, and the lowest rate was 0.3% (8/2,667) in week 75.
- The duplication rate was 0.82% (32/3,888) in the last week (84) of the study.
There was an 84.8% decrease in the duplication rate from week 1 (211 duplicates) to week 84 (32 duplicates), and a 94.6% decrease from the highest (week 1) to the lowest (week 75). The duplication rate of 3.7% Pre-interventions (780/21,081) was reduced to 0.9% Post-interventions (211/23,444); from nearly one duplicate for every 25 orders to fewer than nine in every 1,000 representing a decrease of 75.7%.
The goals of the study were to identify the drugs, which were being duplicated most frequently and create strategies to reduce them. These strategies included the following interventions:
- Many duplicated drugs were defaulted within order sets; wherever possible they were “un-defaulted”
- Many drugs were removed from order sets altogether (and now require a specific order to prescribe)
- Additional duplicate alerts were activated for high-risk and high frequency drugs
- The pharmacy was asked to discontinue certain duplicate orders.
By studying the specific drugs, the type and role of prescribers, the origin of the duplicate orders, and workflow, the authors were able to devise reduction strategies:
- Changes in order sets to avoid overlapping medications
- Changes in work-flow
- Additional training strategies
- Altering pharmacy procedure
- Broadening duplicate warnings.
It was through implementation of these methods that the authors were able to decrease duplicate orders significantly.
The journal article was an interesting read because it took a different approach than most published papers when looking at duplicate orders. Instead of looking directly at the alert function of the CPOE system, the author’s decided to look at the source and work-flow causes that were creating duplicate orders.
- Magid, S., Forrer, C., & Shaha, S. (2012). Duplicate orders: an unintended consequence of computerized provider/physician order entry (CPOE) implementation: analysis and mitigation strategies. http://www.ncbi.nlm.nih.gov/pubmed/23646085
- Magid, S., Forrer, C., & Shaha, S. (2012). Duplicate Orders: An Unintended Consequence of Computerized provider/physician order entry (CPOE) Implementation: Analysis and Mitigation Strategies. Applied Clinical Informatics, 3(4), 377–391. doi:10.4338/ACI-2012-01-RA-0002.