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Human-Centered Design of a Low Molecular Weight Heparin Order Set to Reduce Medication Errors

D'Souza, Anishka; Wu, Phillis; Jung, Laura; Nungaray, Karla; Richman, Mark

The Journal for Healthcare Quality (JHQ): January/February 2019 - Volume 41 - Issue 1 - p e7–e12
doi: 10.1097/JHQ.0000000000000171
Original Article

ABSTRACT Inpatient anticoagulation medication errors for venous thromboembolism (VTE) therapy are common. Our VTE Team identified frequent dosing and duplicate order errors for therapeutic-dose low molecular weight heparin, which (lacking computerized physician order entry) was ordered using blank forms. To decrease such errors, a nonmandatory order form with weight-based dosing and prechecked orders discontinuing existing injectable anticoagulation was developed using human-centered design innovation principles/processes emphasizing end-user engagement in all phases: observation, exploring solutions, and rapid prototyping/feedback. Three physicians independently reviewed ordering errors the year before versus after implementation. Before implementation, 11% of orders contained any error versus 10.5% after implementation (p = .82); 6.2% had a dosing or duplicate therapy error versus 4.2% after implementation (all made when the form was not used; p = .19). No dosing or duplicate therapy errors were made when the form was used. Were the form mandatory, all such ordering errors would likely have been eliminated, leaving 11% before versus 6.3% after implementation orders with any error (p = .015), and 6.2% before versus 0% after implementation orders with duplicate or dosing therapy errors (p < .001). Human-centered design of an anticoagulation order form can reduce anticoagulation order errors; such principles can be applied to other health care innovations, including electronic order sets.

For more information on this article, contact Mark Richman at

The authors declare no conflicts of interest.

© 2019 National Association for Healthcare Quality
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