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

JAMA Netw Open. 2019 Dec 2;2(12):e1916499. doi: 10.1001/jamanetworkopen.2019.16499.


Importance: Electronic health records allow teams of clinicians to simultaneously care for patients, but an unintended consequence is the potential for duplicate orders of tests and medications.

Objective: To determine whether a simple visual aid is associated with a reduction in duplicate ordering of tests and medications.

Design, setting, and participants: This cohort study used an interrupted time series model to analyze 184 694 consecutive patients who visited the emergency department (ED) of an academic hospital with 55 000 ED visits annually. Patient visits occurred 1 year before and after each intervention, as follows: for laboratory orders, from August 13, 2012, to August 13, 2014; for medication orders, from February 3, 2013, to February 3, 2015; and for radiology orders, from December 12, 2013, to December 12, 2015. Data were analyzed from April to September 2019.

Exposure: If an order had previously been placed during the ED visit, a red highlight appeared around the checkbox of that order in the computerized provider order entry system.

Main outcomes and measures: Number of unintentional duplicate laboratory, medication, and radiology orders.

Results: A total of 184 694 patients (mean [SD] age, 51.6 [20.8] years; age range, 0-113.0 years; 99 735 [54.0%] women) who visited the ED were analyzed over the 3 overlapping study periods. After deployment of a noninterruptive nudge in electronic health records, there was an associated 49% decrease in the rate of unintentional duplicate orders for laboratory tests (incidence rate ratio, 0.51; 95% CI, 0.45-0.59), from 4485 to 2731 orders, and an associated 40% decrease in unintentional duplicate orders of radiology tests (incidence rate ratio, 0.60; 95% CI, 0.44-0.82), from 956 to 782 orders. There was not a statistically significant change in unintentional duplicate orders of medications (incidence rate ratio, 1.17; 95% CI, 0.52-2.61), which increased from 225 to 287 orders. The nudge eliminated an estimated 17 936 clicks in our electronic health record.

Conclusions and relevance: In this interrupted time series cohort study, passive visual cues that provided just-in-time decision support were associated with reductions in unintentional duplicate orders for laboratory and radiology tests but not in unintentional duplicate medication orders.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Audiovisual Aids / statistics & numerical data*
  • Child
  • Child, Preschool
  • Electronic Health Records
  • Emergency Service, Hospital / statistics & numerical data*
  • Female
  • Health Plan Implementation / statistics & numerical data*
  • Health Services Misuse / prevention & control*
  • Humans
  • Infant
  • Infant, Newborn
  • Interrupted Time Series Analysis
  • Male
  • Medical Order Entry Systems / statistics & numerical data*
  • Middle Aged
  • Young Adult