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Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions

From the November 5, 2009 issue

Problem: Technology intended to improve safety and efficiency occasionally produces unforeseen error-prone conditions. Such is the case with an order management scanning system (OMSS), which captures a digital image of a handwritten or printed order and routes it to the pharmacy, thus eliminating the need for faxing, courier, or pneumatic tubing systems. The advantages of such technology are numerous and include: decreased time for the order to reach pharmacy; decreased turnaround time from prescribing to availability of medications for administration; electronic filing, maintenance, and easy retrieval of scanned orders in the pharmacy; documentation of quality-associated comments with the use of highlighting and notations; and, potentially, a lower risk of transcription errors since questionable areas of the order can be enlarged. Unfortunately, these advantages are compromised if the pharmacy never receives the orders—a condition that exists when multiple pages of orders are pulled through the scanner at the same time, thus scanning only a single page into the system. The same problem can occur when faxing or copying orders for pharmacy. Staff on the unit who scanned the documents may be unaware of what happened and believe all orders were scanned and sent to pharmacy. The pharmacy staff are also unaware that they should have received multiple pages of orders in their workflow queue. Consequently, important drug therapy may be missed, as described in the following recent event. 

A physician wrote three pages of admission orders for a lung cancer patient with C. difficile colitis and fever. The orders were scanned using the OMSS and received by pharmacy, but one of the pages was pulled through the scanner along with another page. Thus, the pharmacy only received two pages of the orders. The pharmacist did not notice that one page of the admission orders was missing, nor did the nurse who checked the computer-generated medication administration record (MAR). The patient’s physician did not notice the error either, as he did not routinely review the patient’s MAR. Several seizure medications were prescribed on the missing page of orders. By the fourth day of admission, the patient exhibited bizarre behavior and developed confusion and hypoxia. A rapid-response team was called and determined that the patient may have experienced a seizure. The patient was transferred to a critical care unit where his condition worsened, requiring intubation. When the drug levels of his prescribed anticonvulsants were reported as low, the physician discovered the error. Later, the patient was successfully extubated and fully recovered.

While investigating this event, the initial proximate cause was thought to be that the nurse failed to scan the missing page of orders to pharmacy. However, because the hospital had encountered missing pages of scanned orders before, staff quickly realized that the missing page had stuck to one of the other pages during the scanning process. In fact, since January 2006, 16 scanning errors that led to medication omissions—some for the entire hospitalization of the patient—had been reported in the hospital; four of these errors occurred in 2009. Although no patients were seriously harmed because of these prior events, many of the omissions were potentially harmful and required intervention.

For example, a patient with chronic obstructive pulmonary disease (COPD) missed oral doses of aspirin and intravenous doses of furosemide and levofloxacin for 2 days after admission because only four of the six pages of admission orders were received in the pharmacy via the OMSS. Another COPD patient missed doses of methylPREDNISolone and cefTRIAXone for 2 days and experienced chest pain requiring nitroglycerin due to respiratory problems when only three of the four pages of admission orders were received in the pharmacy via the OMSS. A seriously ill patient with pneumonia didn’t receive antibiotics for 3 days when one of the three pages of a preprinted order set was not received in the pharmacy. A patient admitted with pulmonary embolism received the first dose of enoxaparin in the emergency department, but two subsequent doses 12 hours apart were not given because the medication order was on a page that was stuck to another page of admission orders while being scanned. According to the pharmacist who reported these problems to ISMP, the 16 documented cases represent just the tip of the iceberg, as most instances of missing scanned order forms were captured and corrected by a pharmacist or nurse before an omission occurred. In fact, the reporter estimates that each pharmacist on duty catches, on average, one instance of a missing page of orders per day caused by pulling multiple pages through the scanner at the same time. Several weeks ago, one pharmacist caught three missing scanned pages during a single weekend shift.     

In 2007, nurses at this hospital started to document the order number provided on the MAR (generated by the pharmacy computer system) next to the original medication order on the patient’s chart when verifying MARs (meaning they could not verify an order unless pharmacy had entered it and produced an order number). While this helped considerably, the system is not foolproof and problems continue to happen.

ISMP contacted three of the largest companies that offer OMSS—CareFusion (Pyxis Connect), McKesson (Horizon MedComm-Rx), and Omnicell (OmniLinkRx)—to ensure they are aware of the problem of scanners pulling multiple pages through while only the top page is being scanned into the system. In addition to possibly cramming too many pages into the scanner, the companies provided the following possible causes of this problem:

  • Moisture or static electricity can cause pages to cling to each other
  • Staples on forms, folded or creased forms, forms with gummed areas, or attached perforated forms may stick to each other
  • Low-weight paper may stick together (although it is unknown whether thicker paper prevents the problem)
  • Worn or dirty scanner rollers.

Safe Practice Recommendations: If you use OMSS at your facility, an interdisciplinary team of front-line nurses and pharmacists should meet to plan how to reduce the risk of serious drug therapy omissions caused by pulling multiple pages through the scanner at the same time. One important goal is to counteract complacency and remind individuals that they are scanning very important documents to the pharmacy. Consider the following suggestions, many of which also apply when faxing or making copies of orders. 

Prepare pages. Before scanning any order form, remove staples and open any folded or creased sections of the form. Avoid the use of perforated physician order forms when possible. 

Limit the pages. Place the scanner within arm’s reach of staff who scan the orders, and if feasible, ask them to scan one page at a time. This will be easier to enforce if staff know it could prevent errors. To encourage compliance, display a brief set of “send” instructions and post a sign—Warning: To prevent medical errors, NEVER feed more than one order sheet at a time!—on/at the scanner. One potential downside of this practice, in addition to reduced efficiency, is that each page of a group of orders for a single patient may go to a different pharmacy staff member for entry. Thus, it would be best to design your order entry system so that one pharmacist handles all orders from a specific patient care area. Also be sure to number each page of multiple-page orders for a single patient (see below).

Number the pages. If there are multiple pages of orders for a single patient, nursing staff should number the pages before scanning them. Record the page number in a consistent location on the order sheet that will not interfere with the actual orders; number each page sequentially while including the total number of pages (e.g., page 1 of 5, page 2 of 5); and scan only one patient’s orders at a time. Ensure that all multi-page, preprinted order sets have preprinted page numbers on them in the same fashion (e.g., page 1 of 5). For hospitals that already stamp each scanned order, change the stamp template to state: “Scanned page __ of __.”

Monitor receipt. Require the sender to verify the number of pages scanned using the “sent” confirmation feature. Depending on vendor capabilities, a nursing monitor station or “print receipt” feature may be available with the scanning device for staff to view the number of pages that have been scanned and received in the pharmacy. In some cases, you may be able to view the actual pages that were sent to the pharmacy or print a copy of each order that was scanned as validation of receipt. Do not resend the same order more than once without communicating with pharmacy.

Verify MAR entries. If employing pharmacy-generated MARs, consider asking nurses to document the order number (generated by the pharmacy computer system) next to the original medication order in the patient’s medical record when verifying MAR entries. This helps detect any medication orders that have not been entered by pharmacy.

Check charts. Ensure the processes associated with end-of-shift and 24-hour chart checks are robust in their ability to detect any medication orders that have not been transcribed onto the MAR. The process should involve comparing the original orders to the MAR, line by line. If nurses write the pharmacy computer’s order number next to each original medication order on the order form during MAR verification, reinforce with staff conducting chart checks to look for medication orders in the chart without a corresponding number and nurse’s signature.  

Review drug therapy during handoffs. Reports during handoffs in care should include a thorough review of current drug therapy. Such a report, particularly at change-of-shift, can help with the timely discovery of instances when typically prescribed medications—such as antibiotics for an infection—have been omitted by accident.

Prescriber review of current orders. Encourage prescribers to review a printout (or electronic listing) of current medication orders provided by the pharmacy at least every 24 hours, or to review the previous day’s MAR, to help detect omissions in prescribed therapy.  

Clean the scanners. Following the vendor’s instructions, perform routine maintenance and clean the scanners’ rollers and lens regularly or more often if the pages being scanned are unclear.

Reduce variability. Standardize the scanners and user configurations so staff who work on more than one unit will be familiar with their use. 

Empower patients. Encourage hospitalized patients (and families) to speak up if they are not receiving a medication they had been taking at home or a medication their doctor told them they would receive (e.g., antibiotics) in the hospital.

Most of the recommendations above require the user to remember to carry out specific processes, particularly the person scanning the orders to pharmacy. Thus, we have also encouraged vendors of order management scanning systems to seek solutions to the problem through technology improvements, as feasible.

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