Let's get our fax straight!

From the March 11, 1998 issue

PROBLEM: A faxed copy of a pre-printed order (figure 1) arrived in the pharmacy. A pharmacist entered the orders as cefazolin 1 g IV Q 6 hours, vancomycin 1 g IV Q 12 hours, and gentamicin IV 60 mg Q 12 hours. The initial doses of the medications were then sent to the nursing unit to be administered that evening.

Figure 1. Faxed Order

Figure 2. Original order

About an hour later, a pharmacy technician brought the original order from the nursing unit (figure 2). The order was not marked "Fax sent" as protocol stated it should be, which, in this case, was fortunate. Thinking it was a new order, a pharmacist began to enter it in the computer and then saw the previous orders. Since it was unlikely that the orders would have been changed so quickly, the pharmacist sought out the previous order and discovered the problem.

During faxing, the original order became blurred so that the cefazolin looked like "every 6 hours" instead of "every 8 hours," and the gentamicin looked like "60 mg" instead of "160 mg." The pharmacist called and explained to the nurse what happened, changed the cefazolin to every 8 hours on the MAR, and sent the correct dose of gentamicin. The patient did not receive any incorrect doses.

SAFE PRACTICE RECOMMENDATION: We addressed the problem with distorted fax transmissions in our July 3, 1996, issue; however, this is probably a good time to revisit the issue.

A common defense given for using faxed orders is that they are a quick way to get an order to the pharmacy if a drug is needed immediately, or if the nursing unit is located far from the pharmacy, which was the reason given in this case. However, faxing was probably unnecessary in this instance because the order was not for a STAT drug. In addition, despite the distance from the nursing unit to the pharmacy, the order arrived with enough time for the pharmacist to call the unit and then send the correct doses. Of course, the argument can be made that it was a good thing there was re-work in this situation because that is how the error was caught. But if the original orders had not been sent by fax, there would have been no problem.

Faxed orders are appropriate in some situations, and they are definitely better than verbal orders. Still, this process has to be reviewed regularly to guarantee that it is being used in the manner it was originally intended, and that sufficient checks are in place to assure patient safety. Although orders faxed to a pharmacy should not be dispensed until the original is on hand, this is logistically difficult in many operations. Therefore, each faxed order must be examined carefully. If areas appear to be blacked out or faded, or if there is significant phone line "noise" (small, random black marks, streaks or blotchy areas on the paper), make certain they are not in the area of the order. If the area with the order is affected, clarify it before dispensing or wait for the original to arrive. Faxing from order copies increases the risk that a blurred copy will be received; for that reason, some hospitals fax only from the original. Good quality assurance is needed to be sure the form is placed back into the correct patient's chart. Routine maintenance on all fax machines is also a necessity.