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PSNet: Patient Safety Network
Journal Article

Assessment of Unintentional Duplicate Orders by Emergency Department Clinicians Before and After Implementation of a Visual Aid in the Electronic Health Record Ordering System.

Horng S, Joseph JW, Calder S, et al. JAMA network open. 2019;2:e1916499.

The adoption of electronic health record (EHR) systems has led to unanticipated patient safety concerns, such as duplicate orders for tests and medications. This study found that the implementation of a visual aid within the computerized provider order entry (CPOE) system to flag duplicate orders was associated with a 49% decrease in duplicate laboratory orders and a 40% decrease in radiology orders. The authors did not find a decrease in duplicate medication orders. A previous WebM&M commentary describes an adverse event related to duplicate medication orders.