Reducing Therapeutic Duplication in Inpatient Medication Orders.

Abstract

Therapeutic duplication, the presence of multiple agents prescribed for the same indication without clarification for when each should be used, can contribute to serious medical errors. Joint Commission standards require that orders contain clarifying information about when each order should be given. In our system, as needed (PRN) acetaminophen and ibuprofen orders are major contributors to therapeutic duplication. Design and evaluate effectiveness of clinical decision support (CDS) to reduce therapeutic duplication with acetaminophen and ibuprofen orders. This study was done in a pediatric health system with 3 freestanding hospitals. We iteratively designed and implemented two CDS strategies aimed at reducing the therapeutic duplication with these agents: (1) interruptive alert prompting clinicians for clarifying PRN comments at order entry and (2) addition of discrete "first line", "second line" PRN reasons to orders. Therapeutic duplications were measured by manual review of orders for 30-day periods before and after each intervention and 6 months later. Therapeutic duplications decreased from 1485 in the 30 days prior to the first alert implementation to 818 in the 30 days after but rose back to 1208 in the 30 days prior to the second intervention. After discrete reasons were added to the order, therapeutic duplication decreased to 336 in the immediate 30 days and 6 months later remained at 277. Alerts firing rates decreased from 76.0 per 1,000 PRN acetaminophen or ibuprofen orders to 42.9 after the second intervention. Interruptive alerts may reduce therapeutic duplication but are associated with high rates of user frustration and alert fatigue. Leveraging discrete PRN reasons for "first line" and "second line" produced a greater reduction in therapeutic duplication as well as fewer interruptive alerts and less manual entry for providers.