Duplicate Medication Order Errors: Safety Gaps and Recommendations for Improvement

Authors

DOI:

https://doi.org/10.33940/data/2022.9.6

Keywords:

duplicate medication, medication ordering, human factors, health information technology, patient safety

Abstract

Duplicate Med Orders Visual Abstract

Background: Duplicate medication orders are a prominent type of medication error that in some circumstances has increased after implementation of health information technology. Duplicate medication orders are commonly defined as two or more active orders for the same medication or medications within the same therapeutic class. While there have been several studies that have identified contributing factors and described potential solutions, duplicate medication order errors continue to impact patient safety.

Methods: We analyzed 377 reports from 95 healthcare facilities to more granularly define the types of duplicate medication order errors and the context under which these errors occurred, as well as potential contributing factors.

Results: Of the 377 reports reviewed, 304 (80.6%) met the criteria to be defined as a duplicate medication order error. The most frequent duplicate medication order error type was same order (n=131, 43.1%), followed by same therapeutic class (n=98, 32.2%) and same medication (n=70, 23.0%). Errors were identified during different medication process tasks and most commonly during medication reconciliation during the patient’s stay in the hospital (n=72, 23.7%) and during pharmacy verification (n=36, 11.8%). Factors contributing to these errors included health information technology issues (n=63, 20.7%), gaps in care coordination (n=44, 14.5%), and a prior dose or medication order not being discontinued (n=52, 17.1%).

Conclusion: Our results highlight specific areas for practice improvement, and we make recommendations for how healthcare facilities can better address duplicate medication order errors.

Author Biographies

Lucy S. Bocknek, MS, OTR/L, MedStar Health National Center for Human Factors in Healthcare

Lucy Bocknek is a human factors and safety scientist at the MedStar Health National Center for Human Factors in Healthcare.

Tracy C. Kim, MPS, MedStar Health National Center for Human Factors in Healthcare

Tracy Kim is a research and program manager at the MedStar Health National Center for Human Factors in Healthcare.

Patricia A. Spaar, MSN, RN, MedStar Health National Center for Human Factors in Healthcare

Patricia Spaar is a senior clinical safety and research specialist at the MedStar Health National Center for Human Factors in Healthcare.

Jacqueline L. Russell, MD, MS, RN, MedStar Health National Center for Human Factors in Healthcare

Jacqueline Russell is a clinical safety research associate at the MedStar Health National Center for Human Factors in Healthcare and recently completed her doctor of medicine at Georgetown University School of Medicine.

Deanna-Nicole C. Busog, BS, MedStar Health National Center for Human Factors in Healthcare

Deanna-Nicole Busog is a senior research associate at the MedStar Health National Center for Human Factors in Healthcare.

Jessica L. Howe, MA, MedStar Health National Center for Human Factors in Healthcare

Jessica Howe is a research scientist and system safety specialist at the MedStar Health National Center for Human Factors in Healthcare.

Christian L. Boxley, BS, MedStar Health National Center for Human Factors in Healthcare

Christian Boxley is a data analyst at the MedStar Health National Center for Human Factors in Healthcare.

Raj M. Ratwani, PhD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine

Raj Ratwani is the director of the MedStar Health National Center for Human Factors in Healthcare, vice president of scientific affairs at the MedStar Health Research Institute, and an associate professor at Georgetown University School of Medicine.

Seth Krevat, MD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine

Seth Krevat is the senior medical director at the MedStar Health National Center for Human Factors in Healthcare and an assistant professor at Georgetown University School of Medicine.

Rebecca Jones, MBA, RN, Patient Safety Authority

Rebecca Jones (rebejones@pa.gov) is director of Data Science and Research at the Patient Safety Authority and founder and director of the PSA’s Center of Excellence for Improving Diagnosis.

Ella S. Franklin, MSN, RN, MedStar Health National Center for Human Factors in Healthcare

Ella Franklin is the senior director of Nursing Research and Systems Safety Science at the MedStar Health National Center for Human Factors in Healthcare.

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Published

2022-09-16

How to Cite

Bocknek, L. S., Kim, T. C., Spaar, P. A., Russell, J. L., Busog, D.-N. C., Howe, J. L., Boxley, C. L., Ratwani, R. M., Krevat, S., Jones, R., & Franklin, E. S. (2022). Duplicate Medication Order Errors: Safety Gaps and Recommendations for Improvement. Patient Safety, 4(3), 39–47. https://doi.org/10.33940/data/2022.9.6

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Section

Original Research and Articles
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