ISMP Reports of New Medication Errors Leading to Drug Omissions

A recent article from the Institute for Safe Medication Practices (ISMP) that our Maryland-based medication error attorneys have been reading reported that the order management scanning system (OMSS) technology that was created to improve the efficiency and safety of the drug ordering process for doctors and pharmacies, is now experiencing error-prone problems that are leading to medication errors, drug omissions and missed drug therapy in patients.

OMSS is a technology that was created to capture a digital image of a handwritten or printed prescription order and send it to the pharmacy—eliminating faxing, the use of a courier, or the use of pneumatic tubes to transport the information to the pharmacist. The idea behind OMSS was to accelerate the time the prescription hit the pharmacy, speed up the prescription filling process, with electronic filling, easy retrieval of scanned orders, and reduce the risk of transcription errors because the order can be magnified. Unfortunately, according to the article, these OMSS benefits are null and void if the pharmacy never receives the prescription orders.

The problem that is reportedly occurring is that multiple pages of orders are being pulled through the scanner at the same time, and the scanner is only reading a single page at a time—a problem that has also plagued pharmacies with faxing or copying orders in the past. When this problem occurs, staff may not be aware that only one page was scanned, and the pharmacist may not be aware that they should have received multiple pages of orders. As a result, drug omissions can take place, leading to medication mistakes or missed drug therapy.

In one documented case, a physician wrote three pages of admission orders for a patient suffering from lung cancer, as well as difficile colitis and fever. When the orders were scanned with OMSS, the pharmacy only received two pages of the orders, because one page was not pulled through. Neither the nurse who administered the medication the physician, nor the pharmacist noticed the prescription error and omission. The drugs prescribed on the missing page were seizure medications. By the forth day of receiving only a fraction of the medication, the patient was exhibiting behavior that lead the emergency response team to determine that the patient was having a seizure. The patient was transferred to critical care unit, where the doctor figured out the pharmacy mistake, and although the patient required intubation, he ultimately experienced a full recovery.

The ISMP Safe Practice recommendations to prevent OMSS error are to:

• Pull multiple pages through the scanner one page at a time

• Prepare the pages before scanning and remove all staples or folded sections.

• Number the pages so a nursing staff, or pharmacist will know the number of pages to expect.

• Monitor the receipt of the pages, to confirm that all pages were sent

• Check patient charts, and patient’s medical administration record entries (MAR).

• Review patient charts and drug therapy before changing the doctor or nurse shifts

• Encourage patients to be vocal about their medication needs, especially if they are not receiving a medication that they have been taking, or that they have been told they would receive.

• Clean the scanners to ensure clarity and performance

If you or someone you know has been injured by a medication mistake in Maryland or the Washington, D.C. area, contact the attorneys at Lebowitz and Mzhen, LLC for a free consultation. Call us today at 1-800-654-1949.

Order Scanning Systems May Pull Multiple Pages Through the Scanner at the Same Time, Leading to Drug Omissions, Institute for Safe Medication Practices, November 2009

Related Web Resources:

U.S. Food and Drug Administration: Medication Errors

Institute for Safe Medication Practices, (ISMP)

Institute of Medicine, (IOM)

National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP)

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