Patient Safety Tip of the Week
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of texted orders and rescinded its ban on them (TJC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:
- Secure sign-on process
- Encrypted messaging
- Delivery and read receipts
- Date and time stamp
- Customized message retention time frames
- Specified contact list for individuals authorized to receive and
record orders
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We admit it – we are perplexed and astonished the The Joint Commission has rescinded its ban on texting medical orders.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.).
AutoText/AutoCorrect
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.
Security issues
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.
HIPAA issues
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.
Update: see
our January 2017 What's New in the Patient Safety
World column “Joint
Commission Thinks Twice About Texting Orders”
References:
ISMP (Institute for Safe Medication Practices). Safety Brief: “2day” gets “86ed.” ISMP Medication Safety Alert! Acute Care Edition 2009; February 26, 2009
https://www.ismp.org/newsletters/acutecare/archives/Feb09.asp
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
http://www.jointcommission.org/assets/1/6/Update_Texting_Orders.pdf
Medscape Medical News. Reader Poll: Send Orders by Text Message? Medscape Medical News 2016; May 19, 2016
Print “PDF
version”
