Cell Phones and Telephone Orders

Problem

Have you, as a pharmacist, ever haddifficulty receiving a telephoned prescriptiongiven by a doctor over a cellphone? We at the Institute for SafeMedication Practices conducted a surveyasking pharmacists whether theyhad experienced a "case of bad cellular"when receiving telephone orders viacell phones. More than 40% respondedthat they had. Although no one reporteda specific medication error, all clearlyfelt that the opportunity for errorexists. Here is what we learned.

Physicians made cellular calls mostfrequently after office hours, on weekends,while in cars, at home, or at socialevents. Often they seemed to be in ahurry to return to their current activity,and they may not have given the prescribingtask their full attention. Poortransmission clarity and failed connectionsrequiring callbacks were cited asfrequent problems. Factors such as themake and model of the phone, digitalversus analog service, calling area transmission,handset versus speakerphoneuse, and general background noisefrom the road, home, or social eventsall posed threats to accurate transmissionof prescription information, especiallyif a message was left on the pharmacyvoice mail. If follow-up calls wereneeded for clarification, the pharmacistoften did not have the physician's cellphone number. Also, because physiciansoften did not have access to thepatient's medical records at the time ofthe call, they could not answer questionsabout allergies, weight, or othermedications. Likewise, the medicationsthat were prescribed were less likely tobe documented in the patient's record,since it was not available.

Most pharmacists reported difficultyrecognizing the physician's voiceon the phone and verifying the physician'sidentity. Some reported that thistask was especially difficult when theconsumer initiated the call to thephysician while at the pharmacycounter. Another problem cited was apossible breach of patient confidentialitythrough inadvertent or purposefuleavesdropping from peopleclose by or through cellular phonelines. According to ECRI, a nonprofitorganization that tests medical equipment,it is possible to eavesdrop withthe 20% to 30% of cellular phonesthat use older analog technology.

Safe Practice Recommendations

Although it may seem obvious,physicians should refrain from usingcell phones for patient care purposeswhile in the office. Instead, theyshould communicate prescriptionsusing a landline or a fax machine,electronically, or hand the prescriptionto the patient. If the prescribermust use a cell phone outside of theoffice, pharmacy personnel should askthe prescriber to spell the patient'sname and the drug name and to designatethe dose clearly. Pharmacy personnelshould read back the order, asit was understood, before discontinuingthe call. If the connection is poor,prescribers should be told to call backon a landline. Prescribers should beencouraged not to leave messages onautomated answering devices in thepharmacy. Whenever possible, pharmacistsshould view the patient's computerprofile while the caller is on thephone to ensure that the order isapplied to the correct patient and thatallergies and other clinical informationare available.

For security verification and questions,pharmacy personnel should askprescribers to leave a cell phone numberand an office number. If a patientinitiates the call in the presence of apharmacist, the prescriber should beasked to call the pharmacy back usingan office phone line. Some pharmacistswill not accept prescriptions forscheduled drugs given over a cellphone. Because confidentiality cannotbe ensured, conversations with physiciansnever should be made orreceived in the presence of otherpatients.

Dr. Kelly is the editor of ISMPMedication Safety Alert! Community/Ambulatory Care Edition.

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Report MedicationErrors

The reports described here werereceived through the USP MedicationErrors Reporting Program, which is presentedin cooperation with the Institutefor Safe Medication Practices (ISMP).ISMP is a nonprofit organization whosemission is to understand the causes ofmedication errors and to provide timecriticalerror-reduction strategies to thehealth care community, policy makers,and the public. Throughout this series,the underlying system causes of medicationerrors will be presented to help readersidentify system changes that canstrengthen the safety of their operation.

If you have encountered medicationerrors and would like to reportthem, you may call ISMP at 800-324-5723 (800-FAILSAFE) or USP at 800-233-7767 (800-23-ERROR). ISMP'sWeb address is www.ismp.org.