/publications/issue/2004/2004-07/2004-07-8054

"Fax Noise" Can Result in Medication Errors

Author: Kate Kelly, PharmD, and Allen J. Vaida, PharmD, FASHP

Problem

Most health care practitioners would agree that facsimile (fax) machines have facilitated communication of prescriptions. There are, however, inherent problems associated with this technology. In fact, a recent article in the Journal of Managed Care Pharmacy found that prescriptions received by fax required a greater number of clarification calls than those received by other methods of communication.1

We received a report from a longterm care facility about a patient who had been receiving Neurontin (gabapentin) 600 mg tid. An order had been faxed to the pharmacy that the pharmacist thought read to change the Neurontin dose to "300 mg 1 tab qid." The change was made, and the new dose was sent to the facility.

Later, when the pharmacist received the original order and compared it with the faxed order, he realized that the physician had actually requested a change to "800 mg 1 tab qid." The left side of the order had been cut off during the fax transmission, making the "8" look like a "3." Fortunately, because the pharmacist had been sent the original order for comparison, he quickly realized the mistake. Unfortunately, not all outpatient pharmacies receive the original prescription for comparison.

In another report, a faxed prescription was received at a pharmacy for what appeared to be for Monopril (fosinopril) "10 mg #90 one tablet daily." Despite the fact that the fax machine created a definite vertical streak that ran between the drug name and the strength, the pharmacist felt confident in her interpretation of the prescription. Unfortunately, the prescription was actually for "40 mg." The streak had run through the "4" in "40 mg," making it look like "10 mg" instead.

A prescription (see Figure) was faxed to a mail-order pharmacy. Look at the bottom order for "Lisinopril/hctz." (Note: ISMP does not condone the use of the abbreviation "hctz.") The pharmacist interpreted this order as "20/25 mg." What the prescriber had actually written, however, was "20/12.5 mg." A subtle vertical gap in the faxed copy (which also can be seen "breaking" the circles around "3 months supply") had obliterated the "1" in "12.5." In addition, the pharmacist reading the order had misinterpreted the decimal point as one of many stray marks.

Safe Practice Recommendations

"Fax noise" (the random marks and streaks on faxes) is an inherent problem with this technology, and it may be more common with old or poorly maintained fax machines. Usually, fax noise is just an inconvenience. In the case of prescriptions, however, there is a very real chance that a patient could be harmed by misinterpretation caused by fax noise. To manage this risk, the pharmacist should instill safeguards for the fax process. Such safeguards include the following:

Drs. Kelly and Vaida are both with the Institute for Safe Medication Practices (ISMP). Dr. Kelly is the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition, and Dr. Vaida is the executive director of ISMP.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: astahl@mwc.com.


Report Medication Errors

The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). ISMP is a nonprofit organization whose mission is to understand the causes of medication errors and to provide time-critical error-reduction strategies to the health care community, policy makers, and the public. Throughout this series, the underlying system causes of medication errors will be presented to help readers identify system changes that can strengthen the safety of their operation.

If you have encountered medication errors and would like to report them, you may call ISMP at 800-324-5723 (800-FAILSAFE) or USP at 800-233-7767 (800-23-ERROR). ISMP's Web address is www.ismp.org.

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Pharmacy Times and the Institute for Safe Medication Practices (ISMP) would like to make community pharmacy practitioners aware of a publication that is available.

The ISMP Medication Safety Alert! Community/ Ambulatory Care Edition is a monthly compilation of medication-related incidents, error-prevention recommendations, news, and editorial content designed to inform and alert community pharmacy practitioners to potentially hazardous situations that may affect patient safety. Individual subscription prices are $45 per year for 12 monthly issues. Discounts are available for organizations with multiple pharmacy sites. This newsletter is delivered electronically. For more information, contact ISMP at 215-947-7797, or send an e-mail message to community@ismp.org.