Duplicate Medication Order Errors: Safety Gaps and Recommendations for Improvement

Background: Duplicate medication orders are a prominent type of medication error that in some circumstances has increased after implementation of health information technology. Duplicate medication orders are commonly defined as two or more active orders for the same medication or medications within the same therapeutic class. While there have been several studies that have identified contributing factors and described potential solutions, duplicate medication order errors continue to impact patient safety. Methods: We analyzed 377 reports from 95 healthcare facilities to more granularly define the types of duplicate medication order errors and the context under which these errors occurred, as well as potential contributing factors. Results: Of the 377 reports reviewed, 304 (80.6%) met the criteria to be defined as a duplicate medication order error. The most frequent duplicate medication order error type was same order (n=131, 43.1%), followed by same therapeutic class (n=98, 32.2%) and same medication (n=70, 23.0%). Errors were identified during different medication process tasks and most commonly during medication reconciliation during the patient’s stay in the hospital (n=72, 23.7%) and during pharmacy verification (n=36, 11.8%). Factors contributing to these errors included health information technology issues (n=63, 20.7%), gaps in care coordination (n=44, 14.5%), and a prior dose or medication order not being discontinued (n=52, 17.1%). Conclusion: Our results highlight specific areas for practice improvement, and we make recommendations for how healthcare facilities can better address duplicate medication order errors.