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May 24, 2016
Texting Orders -
Is It Really Safe?
In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we noted that texted orders were not acceptable as per The Joint Commission. And for years we have shown in our medication safety presentations a texted order highlighted by ISMP “Slomag,” 64 mg TID “2Day,” that demonstrates how texted orders may be very confusing (ISMP 2009).
But now the Joint Commission has just reconsidered the issue of texted orders and rescinded its ban on them (TJC 2016a, TJC 2016b). According to the new TJC standards healthcare organizations may allow orders to be transmitted through text messaging provided that a secure text messaging platform is implemented that includes the following:
The Joint Commission further notes that the required elements of a complete medication order and actions to take when orders are incomplete or unclear must be clearly spelled out by the organizations and that policies and procedures for text orders should specify how orders transmitted via text messaging will be dated, timed, confirmed, and authenticated by the ordering practitioner. That also includes determining how text orders will be documented in the patient’s medical record.
We admit it – we are perplexed and astonished the The Joint Commission has rescinded its ban on texting medical orders. While we are big fans of use of technology in healthcare, opening up the door to texting orders is likely to create several patient safety vulnerabilities. The Joint Commission’s original ban on text messaging apparently was based primarily on the issue of how secure text messaging was. Since secure text messaging platforms are now available and such systems have been used successfully to facilitate other important aspects of patient care, The Joint Commission apparently feels that rescinding the ban on texting orders is appropriate. However, there are several issues that apply to texting orders above and beyond the use of texting for conveying other sorts of patient information.
Many CPOE systems currently have available remote access via smart phone applications so we would wonder why anyone with such systems would allow text orders at all. But many healthcare organizations may not have such capabilities and will be considering the use of texted orders in view of The Joint Commission’s new position. A recent survey of Medscape readers shows over 70% of respondents looking at texted orders favorably (Medscape 2016) so we anticipate many healthcare organizations are likely to adopt their use. But below are some of the issues that make us leery of texting orders:
Bypassing CDSS tools
One problem that immediately comes to mind is that many EMR systems have an order entry pathway used by nurses (or pharmacists) that is distinct from the typical CPOE pathway in which physicians enter orders. Alerts and other clinical decision support tools available on CPOE may not be available on these alternate order entry pathways. Hence, a texted order would require a nurse to actually enter the order and important patient safety safeguards may be bypassed. Each organization would have to ensure that all the CDSS tools and alerts normally available to the physician would also be available to the person charged with actually entering the order into the system.
Taking the easy way
Texting orders may also be a path for shortcuts and workarounds. We’ve previously seen a clinical decision support system (CDSS) implemented in attempt to optimize ordering blood products. Physicians began to order blood products instead via verbal orders because it was easier to do. This bypassed the patient safety measures that had been built into the CDSS. Particularly since alert fatigue is so widespread we can anticipate that texting orders will be more often resorted to as a shortcut to avoid being bombarded with alerts.
Ordering in a vacuum
Thirdly, if a physician (or other professional allowed to enter orders) is texting in orders, he/she is likely in a remote location where he/she does not have access to the EMR. Hence, important clinical information that might influence the order won’t be available. We are especially concerned when “covering” physicians, who are not familiar with the patient, are texting in orders.
Promoting telephone tag
Fourthly, since there will be strict rules regarding the format and content of texted orders, we anticipate that a substantial number of orders will not meet requirements. When that happens, nurses (or pharmacists) will have to call or otherwise contact the prescriber and the subsequent “telephone tag” will likely add additional burdens to both nurses and physicians.
At least with verbal orders, the nurse receiving the order has the prescriber on the phone and can (and must) ask the appropriate questions. They must use readback and spellback to ensure they get the order correctly and get other clarifications. In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we encouraged those receiving verbal orders to also try to provide context for the ordering provider (allergies, lab values, other medications, medical conditions, etc.).
This one is the lurking giant. Anyone who has sent text messages from their smart phone is often surprised when they know they typed in a correct word yet another word has popped up in its place! That is the AutoCorrect function on your smartphone at work. A related function, AutoText, typically pops up a suggested word after you type in the first several letters of a word. If you happen to hit return (or some other method on your particular smart phone) the suggested word is placed in the text. Of course, if you are paying attention you will note that AutoText or AutoCorrect has inserted a wrong word and you will edit it. But someone who is the least bit distracted might overlook the inadvertent word substitution and send the text message with the name of the wrong drug instead. AutoText and AutoCorrect are great tools that help you in everyday activities and don’t usually result in any harm. But if you are texting orders and such an inadvertent word substitution occurs you may cause major harm. Imagine that you typed in what you thought was “hydrocortisone” and instead “hydrocodone” was substituted. We’d go as far as saying that AutoText and AutoCorrect should be disabled on any device that will be sending orders via text message.
Actually, one feature required for texted medical orders that may be better than verbal orders is verification of the prescriber. In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we pointed out that most facilities accepting verbal orders really have no means of verifying who is actually on the phone! When we ask nurses the usual response we get is “Well, we know their voices.”! At least a Joint Commission approved order texting system would have a means of identifying the prescriber. While that would likely be via an ID and password that could be “stolen”, those same vulnerabilities apply to use of CPOE in the hospital.
That an order was received, verified, and accepted needs to be conveyed back to the ordering physician. That also would likely be via a text message. So that raises the additional HIPAA issue about having patient information on a device (smartphone, tablet, etc.) that might accidentally be left somewhere.
These, and probably several others we did not think of yet, certainly raise our antennas about the patient safety issues associated with texting orders. What The Joint Commission should have done would be to grant a waiver to several healthcare organizations to pilot the concept of order texting and learn about its efficacy, safety, and unintended consequences before allowing everyone to jump on board. Perhaps they have already done that but we don’t see it in their preliminary announcements. We predict by this time next year we’ll be seeing lots of incidents related to texted orders being reported. Of concern is that many of these will simply be buried under the category of “medication errors” and the actual impact of texted orders will not be uncovered in a timely fashion.
We would highly recommend that any hospital or other healthcare facility contemplating use of text orders audit 100% of all such orders for at least 6 months and then incorporate some sort of periodic auditing/monitoring into the QI programs thereafter. You can also expect The Joint Commission to issue some further guidance on the issue by the end of June.
ISMP (Institute for Safe Medication Practices). Safety Brief: “2day” gets “86ed.” ISMP Medication Safety Alert! Acute Care Edition 2009; February 26, 2009
TJC (The Joint Commission). Orders – Texting. What is The Joint Commission's position on texting orders? The Joint Commission 2016
TJC (The Joint Commission). Update: Texting Orders. Joint Commission Perspectives 2016; 36(5): 15
Medscape Medical News. Reader Poll: Send Orders by Text Message? Medscape Medical News 2016; May 19, 2016
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We’ve done multiple columns on the unintended consequences of contact isolation precautions (see the list at the end of today’s column). Patients in contact isolation have less contact by healthcare workers (and visitors) and this may lead to errors and omissions in care and other unintended consequences like decubiti, delirium, falls, and fluid/electrolyte disorders among other preventable adverse events.
Morgan and colleagues, who have done much of the work we’ve previously cited on adverse consequences of contact isolation, have reconsidered contact precautions for endemic VRE and MRSA (Morgan 2015). They did a literature review, a survey of the SHEA Research Network members on use of contact precautions, and a detailed examination of the experience of a convenience sample of hospitals not using contact precautions for MRSA or VRE. They found that there is no high quality data to support or reject use of contact precautions for endemic MRSA or VRE and that hospital practices are widely varied. They concluded that higher quality research on the benefits and harms of contact precautions in the control of endemic MRSA and VRE is needed and that until more definitive data are available, practices in acute care hospitals should be guided by local needs and resources.
Most guidelines for contact precautions have been aimed at healthcare workers. But what about visitors? Last year SHEA (Society for Healthcare Epidemiology of America) reviewed the evidence, which is scant, and developed a consensus statement to deal with the issue in visitors (Stokowski 2016). The guidelines take into account several scenarios and recognize that visitors are unlikely to transmit pathogens in certain circumstances and they take into account practical considerations as well. Important considerations are the specific pathogen, the underlying infectious condition, and the endemicity of the organism in the hospital and the community. Therefore, recommendations really need to be on a case by case basis.
The guideline, of course, stresses the importance of hand hygiene and recommends all visitors should perform hand hygiene before entering and immediately after leaving a patient room. They note that hand washing with soap and water and proper use of an alcohol-based hand rub are acceptable. They stress the importance of ensuring that sinks and alcohol-based hand rub stations are easily accessible to visitors. Note our April 2016 What's New in the Patient Safety World column “Nudge: An Example for Hand Hygiene” cited an article (Hobbs 2016) which demonstrated that when the hand sanitizers were placed in the middle of the lobby (with limited landmarks or barriers) visitors were 5.28 times more likely to use them.
The SHEA guideline says that visitors should be educated on the importance of frequent hand hygiene in the hospital setting and on the available options and proper techniques for performing hand hygiene. But they note that such education must be repeated often, particularly since conditions may change during a hospitalization. While most hospitals use signage to help visitors understand proper hand hygiene, few use oral/verbal education for visitors.
Perhaps somewhat surprising to some is that contact precautions might not always be needed for visitors in areas where MRSA or VRE are endemic. But if the visitor is likely to interact with multiple patients or if the patient is immunocompromised or if the visitors cannot perform good hand hygiene then contact precautions (gowns, gloves, etc.) should be used just as healthcare workers would use. In some cases hospitals might further limit or preclude visitation. But with some pathogens, like Clostridium difficile and Norovirus or extensively drug-resistant gram-negative organisms, full contact precautions would be recommended. Exceptions might be family members or other close contacts who would have likely already been exposed to those from a symptomatic patient.
For patient rooms under droplet precautions visitors would be expected to wear appropriate masks though, again, exceptions might be family members or other close contacts who would have likely already been exposed to those from a symptomatic patient. However, if the latter are symptomatic (eg. cough, fever) they would not likely to be allowed to visit anyone in the hospital. Incubation periods of the specific organism and virulence of the organism might also need to be taken into account in any recommendations. For patients on airborne restrictions (eg. TB or SARS) surgical masks would be used and visitors may require fit testing for recommended masks.
For known outbreaks or suspected infection with serious organisms (eg. Ebola) visitors would likely be restricted.
For visitors to patients with extended stays, isolation precautions are probably not practical and even wearing personal protective equipment (PPE) may be of unclear benefit but would be recommended when assisting in care delivery and contact with blood, body fluids, or non-intact skin is anticipated.
They have special considerations for family and household contacts of neonatal/pediatric patients, again noting a paucity of evidence to inform guidelines. They note how isolation precautions can interfere with bonding, breastfeeding, and family-centered care. But they also note the importance of distinguishing family and household visitors from non-household visitors.
The guidelines further note that “hospitals should only consider writing policies regarding visitors when they can be realistically enforced and regularly evaluated for compliance”. The Stokowski article notes that 77% of hospitals do not have active programs for monitoring visitor compliance with recommendations.
The guidelines are available from SHEA in pocket card format (SHEA 2015). They are also available on the SHEA apps for iOS and Android devices.
Decisions about who and when to use contact precautions should be made considering the potential benefits and potential harms, the clinical scenarios and epidemiology. Such decisions should be made on a case-by-case basis in most circumstances and you need to consider both healthcare workers and visitors. If you do implement contact precautions, make sure that your care plans include appropriate interventions and monitoring to ensure that patients on contact precautions get all their medical and psychological needs met.
Some of our prior columns on the unintended consequences of contact isolation:
Some of our other columns on handwashing and hand hygiene:
January 5, 2010 “How’s Your Hand Hygiene?”
December 28, 2010 “HAI’s: Looking In All The Wrong Places”
May 24, 2011 “Hand Hygiene Resources”
October 2011 “Another Unintended Consequence of Hand Hygiene Device?”
March 2012 “Smile…You’re on Candid Camera”
August 2012 “Anesthesiology and Surgical Infections”
October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”
November 18, 2014 “Handwashing Fades at End of Shift, ?Smartwatch to the Rescue”
January 20, 2015 “He Didn’t Wash His Hands After What!”
September 2015 “APIC’s New Guide to Hand Hygiene Programs”
November 2015 “Hand Hygiene: Paradoxical Solution?”
April 2016 “Nudge: An Example for Hand Hygiene”
Morgan DJ, Murthy R, Munoz-Price LS, et al. Reconsidering Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus. Infect Control Hosp Epidemiol 2015; 36(10): 1163-1172
Stokowski LA, reviewed by Munoz-Price LS. Hospital Visitors and Isolation Precautions: Clearing Up the Confusion. SHEA (Society for Healthcare Epidemiology of America). In Medscape April 29, 2016
Hobbs MA, Robinson S, Neyens DM, Steed C. Visitor characteristics and alcohol-based hand sanitizer dispenser locations at the hospital entrance: Effect on visitor use rates.
Am J Infection Contol 2016; 44(3): 258-262
SHEA (Society for Healthcare Epidemiology of America). Expert Guidance: Isolation Precautions for Visitors. Published: 4/10/2015
A best practices guideline “Optimal Perioperative Management of the Geriatric Patient” jointly developed by the American College of Surgeons and the American Geriatrics Society was recently published (Mohanty 2016).
As you’d expect, there is a preoperative emphasis on establishing goals, expectations and preferences for the patient. That also includes ensuring that there is an advance directive in place and that a health care proxy has been identified. And, where appropriate, consideration should be given to obtaining a palliative care consultation.
Preoperative care should also include a shortened liquid fasting period (clear liquids up to two hours before surgery). Discontinuing non-essential medications but ensuring that the patient is compliant with essential medications is important. Best practices for DVT prevention and antibiotic prophylaxis are also discussed.
Intraoperative management includes attention to fluid and hemodynamic status but also stresses use of regional anesthesia techniques and multimodal opioid-sparing analgesia techniques and reducing postoperative nausea. Prevention of decubiti or nerve damage are important and preventing postoperative pulmonary complications are stressed. Patients should also continue indicated cardiac medications. Avoiding hypothermia is another important consideration.
The postoperative section contains a good discussion on preventing and managing delirium and fall prevention and prevention of UTI’s, topics we’ve discussed in numerous columns. A section on nutritional needs is very good. The postoperative section even includes a postoperative rounding checklist. There are also very good discussions on functional decline and care transition planning.
Overall, this is a concise yet focused document with excellent recommendations. It is also very well referenced with links to the cited documents.
Mohanty S, Rosenthal RA, Russell MM, et al. Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the ACS NSQIP/American Geriatrics Society. J Amer Coll Surg 2016; Published online: January 4 2016
We’ve done numerous columns on wrong patient errors and confusion over patient names. However, a recent article in Pharmacy Times (Ross 2016) shows how such errors can occur outside the hospital and be propagated to the hospital.
A pharmacy dispensed a medication intended for a patient named Florence Frost instead to an elderly patient named Margaret Forrest. That medication was the oral hypoglycemic agent gliclazide and it apparently led to hypoglycemic brain injury and other complications in Margaret Forrest. She was found unconscious and admitted to a hospital. At the hospital, the staff thought she was patient Frost because a paramedic had grabbed a box of medication from the apartment that had Frost’s name on it.
The pharmacy, as do most pharmacies, keeps patient medications on shelves in alphabetical order. So it is not surprising that a pharmacist or pharmacy technician might accidentally pick up a medication intended for another patient and dispense it. In our discussions on patient safety with lay people we emphasize the need for them to identify they have the right medication at the pharmacy and that it is intended for them (verifying their name is on the prescription). But one can easily see how someone with impaired vision or cognition may fail to verify that.
And even after hospitals recognize wrong medications and stop them we’ve all seen wrong medications get propagated in medication lists in our copy-and-paste world (see our April 5, 2016 Patient Safety Tip of the Week “Workarounds Overriding Safety”).
Patient identification errors remain frequent and this year were ranked number 2 on ECRI Institute’s Top 10 Patient Safety Concerns for 2016 (see our May 2016 What's New in the Patient Safety World column “ECRI Institute’s Top 10 Patient Safety Concerns for 2016”).
Ross M. Woman Dies from Alleged Dispensing Error. Pharmacy Times 2016; Published Online: Thursday, March 24, 2016
Every year ECRI Insitute publishes its Top 10 list of patient safety concerns. Here is their Top 10 list for 2016:
The first two are no surprise, given our frequent columns on issues related to healthcare IT and wrong patient issues. Also, the issue of inadequate management of behavioral health problems in non-behavioral health settings has been a frequent topic for us (many columns on suicide on general hospital units, wandering and elopement, and violence in healthcare).
We’ll let you go to the full ECRI list for details. Click here to go to the ECRI Institute site where you can download the list.
ECRI Insitute. Top 10 Patient Safety Concerns for Healthcare Organizations 2016.
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