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.

This study evaluated the efficacy of reviewing ED return visits that result in an ICU admission to determine if they were associated with deviations in care and to understand the common errors. They found that of patients who were return ED visits and admitted to the ICU, 44% (223 cases) returned for reasons associated with the index visit and, in those, 14% (31 cases) had a deviation in care at the index visit. Implementing a standard diagnostic process of care framework to those 31 cases with a deviation in care, 47.3% had a failure in the initial diagnostic pathway. The authors concluded reviewing 14 day returns with ICU admissions contribute to better understanding of diagnostic and systems errors.