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We’ve done multiple columns on problems created by use of fax in healthcare. But, it just won’t go away! A recent opinion column in the Toronto Star (Singh 2021) serves as a reminder that fax machine use in healthcare just won’t die!
The problem really is one of interoperability, or rather, lack of interoperability. Singh notes that millions of medical records are faxed in Ontario every month. He points out that doctors’ offices and hospitals use various electronic medical record systems to document patients’ medical information, but if they want to send a patient to a specialist or a prescription to a pharmacy, they often need to print out the paperwork and fax it.
He compares that to the equivalent of drafting an email, printing it out, and then mailing it to the recipient.
Moreover, Singh notes that about 20% of faxes sent on traditional fax machines fail daily. That leads to many hours of unnecessary work and inefficiency. That leads to errors, lost patient information, and slows down the process of getting patients connected to the health care they need.
Beth Gerritsen, who did a Masters thesis on fax usage in Ontario, notes that the COVID-19 pandemic has exacerbated problems related to use of fax in healthcare (Gerritsen 2021). She notes that, before the pandemic, the healthcare system’s reliance on the fax was embarrassing, but now it’s a critical failure point for the entire system. Her work on fax usage in Ontario showed that:
Gerritsen notes that, during the pandemic, clinicians stepped up with a quick shift to virtual care in order to support patients but quality virtual care needs proper support from digital infrastructure. She notes that a fax failure of a prescription or lab order after a virtual visit critically impacts a patient and nobody should experience a delay in a referral for specialty care because of a misdirected or a failed fax transmission.
She goes on to discuss the steps Ontario needs to take to move away from use of fax in healthcare.
Though both Singh and Gerritsen are discussing use of fax in Ontario, the situation in the US is not much better. Yes, we are making strides in improving interoperability but every hospital and physician’s office in the US still relies on fax at least to some degree. Our January 16, 2018 Patient Safety Tip of the Week “Just the Fax, Ma’am” discussed a podcast on faxing in US doctors’ offices by Sarah Kliff and colleagues on Vox’s “The Impact” series (Kliff 2017). And, even where hospitals and physician’s offices have joined in regional healthcare information exchanges, other third parties that must receive healthcare information (eg. insurers, home care agencies, etc.) may not be included.
It’s worth repeating some of the caveats we raised in our June 19, 2012 Patient Safety Tip of the Week “More Problems with Faxed Orders” and other columns. The problem we have mentioned most often is the missed decimal point (where lines or smudge during fax transmission and printing obscures a decimal point) and the patient receives a 10x overdose of the medication. (In our September 9, 2008 Patient Safety Tip of the Week “Less is More….and Do You Really Need that Decimal?” we cautioned against even using a decimal point when the fraction following the decimal point is clinically irrelevant because that decimal point may be overlooked, especially in faxed orders.) The opposite, of course, may also occur where a smudge on the fax looks like a decimal point (the phantom decimal point) so the patient receives one-tenth the intended amount.
But we’ve also mentioned the case where 2 sheets put into a fax machine stick together and thus only one sheet gets transmitted (see our January 18, 2011 Patient Safety Tip of the Week “More on Medication Errors in Long-Term Care” where we cited such an example from ISMP 2010). Unless you have a cover fax sheet that says “3 pages (cover sheet plus 2 others)” the receiving party may not realize that they are missing a page.
We’ve also seen cases where faxes on multiple patients are sent out at the same time and the receiving party does not recognize that the second sheet is actually for a different patient (see our January 18, 2011 Patient Safety Tip of the Week “More on Medication Errors in Long-Term Care”).
Just as with handwritten orders, on a faxed order with a drug ending in the letter “L” if there is insufficient space between the “L” and the next number, the receiver may think the “L” is actually a “1” (one) and give a dose 10 times too high. And dangerous abbreviations may show up even more frequently on faxed orders than orders written on-site because the provider is more likely to have access to the “do not use” abbreviation list when on-site.
Another mistake is when a person faxes documents that have information on both sides and does not realize that only one side of each page is being faxed.
And remember when you are sending a fax that some elements (eg. text in a different color) may fail to be seen when transmitted. Or that highlighted items (eg. items you tied to stress with a yellow highlighter) may appear blacked out on the received fax! (Reminds me of the time in college when I asked a friend to send me his notes from a class I had missed so I could study for a test the next day. He faxed them and all the important stuff, which he had highlighted with a highlighting marker, was blacked out on the fax!!!).
And one of the most egregious errors of all – faxing to the wrong phone number (the misdirected fax). Ever get a call from the local supermarket that you faxed them a sheet with PHI on it? Your HIPAA compliance officer and risk manager will turn gray when that call comes in! We’ve seen faxes sent to old fax numbers after a physician has moved to a new office and even faxes sent to physicians who have been deceased for four years! And hospital computer systems often have the wrong physician listed as primary care physician, often leading to faxes being sent to the wrong PCP.
ISMP Canada (ISMP Canada 2012) came up with a new fax error – the truncation error. They provide a great example of a faxed order for “dalteparin” where the “da” gets cut off in the fax and the “lt” looks like an “H” on the fax, resulting in what clearly looks like an order for “Heparin”. Click on the link above and you’ll see both the faxed prescription and the original.
Note that prescription has lots of other bad errors on it. It uses the do-not-use abbreviation “U” (for units) as well as 2 other abbreviations that should be avoided (“SQ” for subcutaneous and “QD” for once daily). It has a different dose written above and crossed out. And it does not have listed the indication for the drug. It also has an illegible word following the “QD” (is it nitely? or is it a provider’s signature?). And there is nothing on the prescription to indicate the duration of therapy, amount to be dispensed, whether it should be refilled, etc. Who would have thought one prescription could be used as a primer for medication errors!
ISMP Canada notes the importance of reviewing copies of the fax you send or the one you receive. For instance, in the case given one might have noticed that the name of the hospital was also truncated, which might have been a clue that the medication name was truncated. They also note in the example given that the dosing frequency would have been unusual for heparin (it is usually given twice daily or three times daily rather than once daily), perhaps being another clue to the receiver that there was an error. They also note that including both the generic and brand names on the prescription would have provided another clue to the error. They note the importance of engaging the patient to be on the lookout for errors as well.
We refer you back to our Patient Safety Tips of the Week for June 19, 2012 “More Problems with Faxed Orders” and January 16, 2018 “Just the Fax, Ma’am” for our multiple recommendations on faxing issues.
Our January 2019 What's New in the Patient Safety World column “Still Faxing?” noted initiatives in the UK and the US to eliminate use of fax in healthcare. But we are still not there. Both Singh and Gerritsen use the catchy phrase “Axe the Fax”. It seems that, in politics, catchy 3-word phrases go a long way. Maybe it’s time we all adopt “Axe the Fax”!
See our prior columns on problems related to use of fax in healthcare:
June 19, 2012 “More Problems with Faxed Orders”
January 16, 2018 “Just the Fax, Ma’am”
September 2018 “ECRI Institute Partnership: Closing the Loop”
January 2019 “Still Faxing?”
Singh P, Aggarwal S. We need to axe the fax in health care — now. Toronto Star 2021; March 24, 2021
Gerritsen B. Axe the fax: A primer on fax tech in the 21st century, an Ontario’s healthcare system perspective. Canadian Healthcare Network. The Medical Post 2021
Kliff S, Pinkerton B, Weinberger J, Drozdowska A. It’s 2017. Why does medicine still run on fax machines? Vox “The Impact” (podcast) 2017; October 30, 2017
ISMP (Institute for Safe Medication Practices). Order scanning systems (and fax machines) may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety Alert (Nurse Advise-ERR) 2010; 8(11): 1-2
ISMP Canada. ALERT: Medication Mix-up with a Faxed Prescription. ISMP Canada Safety Bulletin 2012; 12(6): 1-3 June 5, 2012
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