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Case #1 Discussion

The first step is corrective action. The potential duplicate order could have been an ordering error by the physician. Before cancelling the order, the lab customer service representative contacts the two ordering physicians because medical staff members are unhappy when orders are cancelled without notification. It was found to be a duplicate and one was cancelled and only one tube was sent to the blood bank.
Is the cause person related or systematic? The preventative action will differ depending on the root cause. Things that could have been part of the cause of the duplicate order:
  • computer warning about a duplicate order was set incorrectly and no warning was sent when the same physician ordered the second type and screen.
  • process in the lab was not followed and an order was sent from the lab system to the hospital computer system to collect and type and screen.
  • the type and screen was set for a nursing unit collect and was reordered as a stat because it was not collected at the 6:00 am draw.
  • Physician order error. The patient was a potential transplant patient and the physician wanted a confirmation blood type so order two type and screens not knowing they would be collected at the same draw defeating the purpose of the second specimen.
  • Multiple physicians placing orders without reviewing orders already placed.