FAX machine "noise"
= medication errors in waiting
From the July 3,1996 Issue
Problem: Although FAX machines have brought
many beneficial changes to communications, there have also
been numerous cautions about the attendant problems. We recently
saw just how a problem might occur when an order for bleomycin
was received in a hospital pharmacy.
The first order arrived in the pharmacy asking for
a test dose of the drug and then, if no acute reaction was
observed, the administration of 8.2 units of bleomycin. Since
there was no test dose specified, the pharmacist called the
nursing unit for an order. To save time, once the nurse received
the order for the test dose, she sent it via FAX with an original
Pharmacy received the order (figure 1) and prepared to fill
the prescription. Since the dose apparently ordered would
have totaled 13.2 units, and since there was only 1 vial with
15 units remaining in the refrigerator, the pharmacist asked
the pharmacy buyer to order some immediately. At this point
another pharmacist, who also looked at the order, commented
that it was odd that the "test" dose should be almost
the same size as the therapeutic dose. Further preparation
of the doses was halted until the original order was received.
When the original was received, it was evident that the physician
wanted a test dose of 0.5 units. As chance would have it,
an extraneous vertical line on the FAX transmission fell in
exactly the right place to cause confusion.
Safe Practice Recommendation: "Chance"
is a common reason that medication errors occur, and by not
putting safeguards into place we increase our "chances"
of seeing a problem. Certainly any medical order FAXed with
streaking, wavy lines, etc. indicates a need for the equipment
to be repaired immediately. The order must be checked against
the original or should be clarified before any attempt is
made to act upon it. In all truth, no order FAXed into a pharmacy
should be dispensed until the original is on hand. Although
this is perhaps the ultimate fix, it is also the one that
logistically may be the most difficult. FAX machines in health
care institutions are there to allow faster communication
of medical orders. By insisting on waiting for the original,
that benefit is obviated.
Therefore, review each FAXed order carefully. If there appears
to be blacked out or faded out areas, or if there is significant
phone line "noise" appearing as small, random, black
marks or streaks on the paper, make certain it is not in the
area of the order. If the area with the order is affected,
make certain that you either clarify the order before dispensing
or wait for the original to arrive. Scheduled maintenance
checks are also a necessity. Incidentally, use of the abbreviation
"U" for "units" is dangerous because the
"U" is often seen as a zero, four or six.
Figure 1: Vertical streak, caused by "noise",
interferes with readability of bleomycin test dose, making
0.5 unit dose appear to be a 5 unit dose.