Duplicate medication order errors: safety gaps and recommendations for improvement.
Duplicate medication orders, defined as orders for two or more identical medications or same therapeutic class, can result in serious complications if they reach the patient. This study examined the error type (same medication, therapeutic class, or order), when they were recognized, and factors contributing to the error. Importantly, of duplicate orders in the same therapeutic class, the three most common medications were anti-coagulants, a high-risk medication.