Patient safety alert: Facsimile orders

Faxed patient orders and prescriptions that are poorly transmitted or illegible cause medication errors and result in serious injury, including death.

DESCRIPTION OF THE PROBLEM:
The quality of a facsimile copy can vary widely. In addition to the quality of the communicating machines, several other contributing factors have been identified and include:

  • Poor quality of the paper and ink reduces readability

  • Unclear handwriting

  • Extraneous marks interpreted as part of prescription

  • Misinterpretations

  • "Writing over" the dose and/or strength

  • Orders on "ruled paper" unclear when reproduced

SCOPE and SEVERITY:

NCC Medication Error Index Number of Cases
Category I: An error occurred that resulted in patient death 2
Category F: An error occurred that resulted in initial or prolonged hospitalization and caused temporary patient harm 1
Category E: An error occurred that resulted in the need for treatment or intervention and caused temporary patient harm 2
Category D: An error occurred that resulted in the need for increased patient monitoring but no patient harm 1
Category C: An error occurred that reached the patient but did not cause patient harm 7
Category B: An error occurred but the medication did not reach the patient 9

* National Reporting programs used as a source for this data are the  USP-ISMP Medication Errors Reporting program, the FDA MedWatch  Program, and the JCAHO Sentinel Event Reporting Program.

SUGGESTED ACTIONS:
Health care professionals and health care organization should consider the following:

  1. Whenever possible, original written orders should be used.

  2. Orders with "writing over," extraneous marks, or otherwise unclear handwriting should raise an "alert" with the pharmacist/nurse and be interpreted with extra caution.

  3. Create an environment in which it is acceptable and encouraged to question the prescriber if there is any uncertainty about the order.

  4. Continue to report errors associated with the use of facsimile orders so that accurate frequency and severity of these errors can be assessed.

Posted: 07/1999


This information provides notification of situations in which errors may occur. The identification of particular products or brands should not be interpreted as an adverse reflection of the product or manufacturer. The suggestions to avoid medication errors are general and should be properly evaluated before implementation to determine whether they are appropriate for use in particular work environment.