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Therapeutic duplication alert in Epic coming June 3

26 May 2019

SBAR to reduce risk of duplicate medication orders

By: Matt Boles, MD, vice president of medical affairs

Situation/Background: During our recent survey, the Joint Commission issued a citation that identified duplicate medication orders. A workgroup was assembled that included physician leaders to evaluate this risk to our patients. The group discovered that providers outside of the emergency department see minimal FYI alerts about relative duplicate orders they enter. This is a result of system-level Epic alert choices.

Assessment: Epic has functionality that shows a real-time, inline (not a pop-up) alert for duplicate order entries. This involves two items: colored numbering and shading of the duplicates and a brief duplicate warning that hovers over the medication entry area. All providers currently see the shading. If we add the second element (the hovering warning), Epic can notify providers of potential duplicates so they can have the opportunity to correct the orders.  

Recommendation: Allow providers outside of the ED to see this same alert to help mitigate the risk of duplicate medication order entry.

View the complete SBAR and screenshots for more information. If you have any questions about this workflow, please contact me directly at