Original Document Needed to Scan Orders to Pharmacy

Problem: Technology intended to improve safety and efficiency occasionally produces unforeseen error-prone conditions. These may be minimized once the risk has been recognized, especially if the benefits of the technology are far-reaching. Such may be the case with document-imaging technology that captures a digital image of a handwritten order and routes it to the pharmacy, thus eliminating the need for faxing, courier, or tubing systems. The advantages of such technology are numerous and include: decreased time from prescribing to availability of medications for administration; reduced risk of lost orders; electronic maintenance of orders in the pharmacy; and, potentially, a lower risk of transcription errors. Unfortunately, these advantages are compromised if the clarity of the order scanned and sent to the pharmacy is not optimal.

Multiple pharmacists have reported that orders received via document-imaging technology are often poorly legible if the "no-carbon required" (NCR) copy of the order has been scanned, not the original order. In some cases, the order copy scanned may be page three or four within a multi-page NCR order form. Often, such circumstances are also responsible for poorly legible faxed orders.

One hospital pharmacist reported that, when scanning technology was first implemented, errors were occurring daily, and the time commitment to clarify poorly legible orders was significant. Now, several years later, errors are still occurring because pharmacists, who have spent years learning to decipher these orders, now believe they can "figure them out."

Interestingly, one of the features of document-imaging technology-the ability to magnify the order image-may actually contribute to the problem. Although potentially helpful, magnification should not be necessary for clearly written orders that are scanned using the original document. However, magnification has become somewhat of a crutch or a workaround for poorly legible orders, regardless of whether the cause is illegible handwriting or the lack of clarity associated with scanning copies of orders.

The solution seems obvious-the original order should always be scanned. So why does the problem persist in some hospitals? A few practitioners have told us that nurses and unit secretaries do not like to remove the original order from the patient's chart because they are afraid they will forget to return it, or place it on the wrong chart. This worry may be especially prevalent if unit secretaries are unavailable to assist nurses, or if the scanning device or fax machine is not right next to the person who is transcribing the orders.

Several practitioners have also told us that nurses and unit secretaries might be minimizing the problem because they are not aware of the extent and scope of errors that have resulted from faxing and scanning order copies. Also, pharmacists may be unaware of workflow barriers that make it difficult for nurses and unit secretaries to scan or fax the original order. Additionally, using the NCR copy may simply be the result of longstanding habits developed when previous systems were in place to communicate orders to the pharmacy. Order copies, previously sent to pharmacy by courier or tube, are no longer necessary if the original order can be scanned (or faxed) to the pharmacy.

The continued use of multi-page NCR order forms after implementation of scanning or faxing technology is a prime example of failing to evaluate the effects of the technology on the whole medication use system before implementation. Leaving old processes and tools in place that no longer support the new technology can lead to error-prone conditions. One pharmacist provided another apt example. His hospital had implemented document-imaging technology a year ago, but he recently learned that new nurses undergoing orientation were being taught to send pharmacy a scan of the order copy, which in this case was pink and harder to scan, further increasing the risk of a poorly legible image. The procedure for transmitting orders to the pharmacy had never been updated and communicated to all appropriate staff.   

Safe Practice Recommendations

Before implementing document-imaging technology, require an interdisciplinary team to review current medication use processes to evaluate whether they support the safe and efficient use of the technology. Make and communicate important process changes before implementing the technology. If the technology is already in use, or if orders are currently faxed to the pharmacy, have a medication safety team evaluate the current clarity of transmitted orders and interview pharmacy staff to determine the scope of legibility problems.  

The original order form should always be used to scan or fax orders to the pharmacy, and multi-page NCR order forms should be eliminated. This would improve the clarity of the order image and reduce nursing and pharmacy time otherwise spent on clarifying orders. Costs associated with the order forms would also be reduced. (If a decision is made to continue use of multi-page NCR order forms, there should be just a single white copy without lines. However, the risks associated with scanning or faxing copies should be carefully weighed against the benefit of a two-page order form.) A process should also be established to indicate which orders or order sets have been scanned (or faxed) to the pharmacy. For example, some hospitals stamp "faxed" or "scanned" below the orders.

It might be helpful for pharmacists to hold a small focus group with nurses and unit secretaries to examine any concerns they may have with removing original orders for scanning or faxing. The technology cannot be successful unless expressed concerns are addressed, high-speed scanners and fax machines are located close to those responsible for transmitting orders to the pharmacy, sufficient scanners are available, and workload and/or workflow issues are resolved. Mistakes when replacing original orders in the patients' charts can be reduced by requiring staff to fax or scan one patient's orders at a time, each page separately, and to validate that they are returning the orders to the correct patient's chart by comparing two identifiers on the order with information in the patient's medical record. Keeping the chart open until the original orders have been returned has also been helpful.

Those involved in the medication use process should also be made aware of the burden placed on pharmacists and nurses in terms of time and resources for clarification, as well as errors that have resulted when faxing or scanning order copies.

Once computerized prescriber order entry systems have been implemented and fully integrated, scanning or faxing orders will no longer be required. However, until then, there is no reason for this safety breech with this technology to continue if the above-mentioned actions are taken and monitored.