Abstract
Background 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.
Objective The objective of this study is to design and evaluate effectiveness of clinical decision
support (CDS) to reduce therapeutic duplication with acetaminophen and ibuprofen orders.
Methods This study was done in a pediatric health system with three 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” and “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.
Results Therapeutic duplications decreased from 1,485 in the 30 days prior to the first alert
implementation to 818 in the 30 days after but rose back to 1,208 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.
Conclusion 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.
Keywords
clinical decision support - therapeutic duplication - pediatrics
