Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP Facebook

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 to follow.

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.

[D,N,Q, P,T]

Fax Image

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.

Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas - Free CEs
Special Error Alerts
Newsletter Editions
Acute Care
Long Term Care
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officers Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2018 Institute for Safe Medication Practices. All rights reserved