Getting Beyond Interruptive Alerts: Reducing Unintentional Duplicate Orders using a Visual Aid

ImportanceElectronic health records (EHRs) allow teams of clinicians to simultaneously care for patients but an unintended consequence could result in duplicate ordering of tests and medications.\n\nObjectiveWe asked if a simple visual aid would reduce duplicate ordering of tests and medications for busy teams of clinicians in our emergency department by placing a red highlight around the checkbox of a computer-based order if previously ordered.\n\nDesignWe performed an interrupted time series to analyze all patient visits 1 year before and 1 year after the intervention. Significance testing was performed using a negative binomial regression with Newey-West standard errors, correcting for patient level variables and environmental variables that might be associated with duplicate orders.\n\nSettingThe emergency department of an academic hospital in Boston, MA with 55,000 visits annually.\n\nParticipants184,722 consecutive emergency department patients.\n\nExposureIf an order had previously been placed during that ED visit, we cue the user by showing a red highlight around the checkbox of that order.\n\nMain OutcomeNumber of unintentional duplicate orders.\n\nResultsAfter deployment of the non-interrupting nudge, the rate of unintentional duplicates for laboratory orders decreased 49% (incidence rate ratio 0.51, 95% CI 0.45-0.59) and for radiology orders decreased with an incidence rate ratio of 0.60 (0.44-0.82). There was no change in unintentional medication duplicate orders. We estimated that the nudge eliminated 17,936 clicks in our EHR.\n\nConclusions and RelevancePassive visual queues that provide just-in-time decision support are effective, not disruptive of workflow, and may decrease alert fatigue in busy clinical environments.\n\nKey PointsO_ST_ABSQuestionC_ST_ABSCan a simple visual aid reduce duplicate ordering in an electronic health record?\n\nFindingsIn this interrupted time series, the rate of unintentional duplicates for laboratory orders decreased 49% and for radiology orders decreased 40%. There was no change in unintentional medication duplicate orders. We estimated that the nudge eliminated 17,936 clicks in our EHR.\n\nMeaningQuality improvement often relies on changing clinician behavior. We believe guiding clinicians to a right action is better than telling the clinician they have already made an error. Our approach will help reduce alert fatigue and lessen clinician complaints about EHRs.