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
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.