Table 3

Order set items with the highest and lowest risks of order retraction relative to when the same items were ordered a la carte, excluding uncommon order sets used fewer than 100 times

(a) Order set items with the highest risk of retraction relative to a la carte
Order set Item Retraction count (order set) Retraction rate
(order set) (%)
Retraction count
(a la carte)
Retraction rate
(a la carte) (%)
Retraction relative risk
Vascular ICUEsmolol IV33810.942.8
Neurology general ward admitAtorvastatin PO240601.625.0
ED abdominal painPantoprazole IV21006885.318.8
Nursing triage pain management protocolOndansetron PO2671533.618.6
NSTEMI admitAtorvastatin PO333961.917.8
PneumoniaCeftriaxone IV375134.815.7
Medicine general admitWarfarin PO538961.915.3
ICU surgery/trauma admitPantoprazole PO523624211.6
Lung, heart–lung transplant post opPiperacillin–tazobactam IV3604665.610.6
Cardiac surgery admissionPolyethylene glycol74189410.4
(b) Order set items with lowest risk of retraction relative to a la carte
Order set Item Retraction count (order set) Retraction rate
(order set) (%)
Retraction count
(a la carte)
Retraction rate
(a la carte) (%)
Retraction relative risk
BronchoscopyLidocaine injection50.5240.00.01
HaemodialysisHeparin injection20.21645.70.04
Joint replacementNormal saline IV bolus30.122252.70.04
HaemodialysisMannitol IV62.02132.80.06
Bowel resection post opLidocaine injection20.31324.60.06
Comfort careGlycopyrrolate IV20.5615.90.08
Neurosurgery post opLidocaine injection60.34574.10.08
HaemodialysisLidocaine injection30.34574.10.08
Head and neck post opMorphine injection40.5616.10.08
Neurosurgery post opPotassium chloride liquid PO30.44255.30.08
  • The retraction relative risk=(retraction rate from order set)/(retraction rate a la carte). Items in 3a represent those that are particularly poorly aligned with clinician workflow given how much more likely they are ordered in error from the corresponding order set, while items in 3b appear to be particularly well aligned.

  • ED, emergency department; ICU, intensive care unit; IV, intravenous; NSTEMI, non-ST elevation myocardial infarction; PO, by mouth.