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Have you, as a pharmacist, ever had difficulty receiving a telephoned prescription given by a doctor over a cell phone? We at the Institute for Safe Medication Practices conducted a survey asking pharmacists whether they had experienced a "case of bad cellular" when receiving telephone orders via cell phones. More than 40% responded that they had. Although no one reported a specific medication error, all clearly felt that the opportunity for error exists. Here is what we learned.
Physicians made cellular calls most frequently after office hours, on weekends, while in cars, at home, or at social events. Often they seemed to be in a hurry to return to their current activity, and they may not have given the prescribing task their full attention. Poor transmission clarity and failed connections requiring callbacks were cited as frequent problems. Factors such as the make and model of the phone, digital versus analog service, calling area transmission, handset versus speakerphone use, and general background noise from the road, home, or social events all posed threats to accurate transmission of prescription information, especially if a message was left on the pharmacy voice mail. If follow-up calls were needed for clarification, the pharmacist often did not have the physician's cell phone number. Also, because physicians often did not have access to the patient's medical records at the time of the call, they could not answer questions about allergies, weight, or other medications. Likewise, the medications that were prescribed were less likely to be documented in the patient's record, since it was not available.
Most pharmacists reported difficulty recognizing the physician's voice on the phone and verifying the physician's identity. Some reported that this task was especially difficult when the consumer initiated the call to the physician while at the pharmacy counter. Another problem cited was a possible breach of patient confidentiality through inadvertent or purposeful eavesdropping from people close by or through cellular phone lines. According to ECRI, a nonprofit organization that tests medical equipment, it is possible to eavesdrop with the 20% to 30% of cellular phones that use older analog technology.
Safe Practice Recommendations
Although it may seem obvious, physicians should refrain from using cell phones for patient care purposes while in the office. Instead, they should communicate prescriptions using a landline or a fax machine, electronically, or hand the prescription to the patient. If the prescriber must use a cell phone outside of the office, pharmacy personnel should ask the prescriber to spell the patient's name and the drug name and to designate the dose clearly. Pharmacy personnel should read back the order, as it was understood, before discontinuing the call. If the connection is poor, prescribers should be told to call back on a landline. Prescribers should be encouraged not to leave messages on automated answering devices in the pharmacy. Whenever possible, pharmacists should view the patient's computer profile while the caller is on the phone to ensure that the order is applied to the correct patient and that allergies and other clinical information are available.
For security verification and questions, pharmacy personnel should ask prescribers to leave a cell phone number and an office number. If a patient initiates the call in the presence of a pharmacist, the prescriber should be asked to call the pharmacy back using an office phone line. Some pharmacists will not accept prescriptions for scheduled drugs given over a cell phone. Because confidentiality cannot be ensured, conversations with physicians never should be made or received in the presence of other patients.
Dr. Kelly is the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.
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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 timecritical 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.