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Patient Safety Tip of the Week

July 23, 2019

Order Sets Can Nudge the Right Way or the Wrong Way



Standardized order sets are powerful tools that can improve clinician efficiency and improve patient safety. They can “nudge” you in a good way. For example, they can be used to remind you to consider DVT prophylaxis and provide you with the best options for that prophylaxis. Or they can ensure you use correct drug names and dosages that are appropriate. But they can also nudge you in the wrong direction. When hospitals first began to use order sets (paper- or computer-based) there was a tendency to try to cover all contingencies. For example, order sets might include prn orders for sleep meds, laxatives, antacids, etc. Often, these were included so a clinician did not have to be wakened at night to order such medications. Long ago, we recognized that putting too many options in an order set, particularly those using a “checkbox” format, often resulted in inappropriate orders for many patients. In our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” we noted ISMP’s guideline on order sets cautioned against including blanket-type orders (eg. laxatives, sleep meds, antiemetics, antidiarrheals, antacids, etc).


Remember, any options you include in an order set have a good chance of being selected and ordered. For example, if you include Dilaudid/HYDROmorphone as an option for postop analgesia, there is a good chance someone will order it. In our many columns on the dangers of that drug (see list below), we note that many clinicians fail to recognize the equipotency issues of several opioids and that clinicians often underestimate the relative potency of Dilaudid/HYDROmorphone. Hence, we prefer not to include Dilaudid/HYDROmorphone as an option on a standardized order set but, recognizing that there are a few select circumstances where it may be appropriate, you can create a link in your order set to “other analgesics”.


Keep in mind that “default bias” is a very powerful cognitive bias. In our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts” we noted the importance of considering appropriate default options when designing order sets. One of the cognitive biases we see is the “default bias”, in which it is a natural tendency to select default options when several options are possible. In our April 30, 2019 Patient Safety Tip of the Week “Reducing Unnecessary Urine Cultures” we noted how clinicians and researchers at Barnes-Jewish Hospital implemented a program to reduce unnecessary cultures (Munigala 2019). Their intervention consisted of notifications to providers, changes to order sets, and inclusion of urine culture reflex tests in commonly used order sets. The CPOE intervention they implemented was setting the default option to urine dipstick testing followed by a bacterial culture if positive (i.e. reflex testing), rather than a culture alone, This resulted in a 45% reduction in the urine cultures ordered. That intervention saved approximately $104,000 in laboratory costs alone over the 15-month period plus likely savings from reduced antibiotic use and less contribution to the emergence of resistant organisms.


Another recent study (Strauss 2019) used a multifaceted strategy to reduce unnecessary ordering of certain laboratory tests that add little value to patient management at significant cost. Aspartate aminotransferase (AST), commonly ordered with alanine aminotransferase (ALT) and blood urea nitrogen (BUN), commonly ordered with creatinine (Cr), were the examples they targeted. They created guidelines for appropriate indications of AST and BUN testing, provided education with audit and feedback, and removed AST and BUN from institutional order sets. This resulted in ratios of AST/ALT and BUN/Cr decreasing significantly over the study period (0.37 to 0.14, 0.57 to 0.14, respectively), and  a projected annualized cost savings of $221,749.


Li and colleagues (Li 2019) recently evaluated how well standardized order sets were serving their clinicians. Using data from the EHR on all orders of medication, laboratory, imaging and blood product items, they focused on four indicators: infrequent ordering of order set items, rapid retraction of medication orders from order sets, additional a la carte ordering of items not included in order sets and a la carte ordering of items despite being listed in the order set.


Ordering rates for individual order set items varied greatly, ranging from 0.001% to 100%, with a median of 4.1%. Laboratory items had higher median ordering rates (11.5%) in general than medications (2.3%,), imaging (4.7%) and blood product items (2.6%).


Regarding medication orders retracted within 30 minutes, 2.2% ordered via order sets were retracted, compared to 3.9% that had been ordered ala carte. But there was considerable variability. 3% of medications ordered from order sets were significantly more likely to be retracted than if the same medication was ordered ala carte. Order set medication items with ordering rates in the lowest quartile were approximately twice as likely to be retracted than those in the other quartiles.


They then looked at items that were additionally ordered ala carte within 10 min. of an order set use more often than the median ordering rate of items in the corresponding order set. 39% of order sets had such an item commonly added ala carte, with a median of 4 distinct additional a la carte items per order set.


Lastly, they looked at items that were ordered ala carte even though they had been in the order set used. 45% contained at least one such ‘a la carte over order set’ item, with a median of 4 distinct items per order set.


Overall, their analysis found that many order sets were seldom used and many order sets

may be “bloated” with low yield items. Rarely used items were also more likely to be rapidly retracted. Furthermore, many order sets may also be missing items that users need.


The Li study emphasizes the critical importance that any time you roll out a new order set (or a new alert or other clinical decision support tool, for that matter) you must monitor usage of that order set. You need to review how often it is used and whether the desired goals are achieved, and whether unintended consequences occur. You need to solicit feedback from users. You need to have a formal process by which you assess all the above. Sometimes our most well-intended evidence-based patient safety interventions end up causing unintended consequences that may produce patient harm. And, don’t forget you need to review all your order sets periodically. Clinical evidence and guidelines often change over time and you don’t want to have items in your order sets that are outdated and no longer recommended practices.


Our discussion on order sets should also include some comments on “Do not use” abbreviations. You, of course, should be using ISMP’s List of Error-Prone Abbreviations (ISMP 2017), rather than The Joint Commission’s more succinct list of “Do not use” abbreviations. In our several columns on dangerous abbreviations (see, for example, our December 22, 2015 Patient Safety Tip of the Week “The Alberta Abbreviation Safety Toolkit”), we note that, as you update your “Do not use”, you need to review all your order sets. When we did this at one hospital, we found numerous dangerous abbreviations still sitting in some old order sets, some “customized” order sets used by individual clinicians, and even in some third-party vendor order sets.



See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:



See our series of columns on the dangers of Dilaudid/HYDROmorphone listed below:






Munigala S, Rojek R, Wood H, et al. Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center. Infection Control and Hospital Epidemiology 2019; Published online: 21 February 2019: 1-6



Strauss R, Cressman A, Cheung M, et al. Major reductions in unnecessary aspartate aminotransferase and blood urea nitrogen tests with a quality improvement initiative

BMJ Quality & Safety Published Online First: 09 May 2019



Li RC, Wang JK, Sharp C, et al. When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. BMJ Quality & Safety 2019; Published Online First: 04 June 2019



ISMP (Institute for Safe Medication Practices). List of Error-Prone Abbreviations. ISMP 2017; October 2, 2017






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