Cell phones and patient safety

Does your doctor telephone prescriptions over a cell phone? We asked pharmacists if they had ever experienced a "case of bad cellular" when receiving telephone orders via cell phones. Over 40 percent responded that they did and all clearly felt that the opportunity for a medication error exists.

Here's what we learned. Physicians made cellular calls most frequently after office hours, on weekends, while in cars, at home or at social events. Often they seemed to be in a hurry to return to their previous activity and may not have given the prescribing task their full attention. Poor transmission clarity and failed connections requiring callbacks were cited as frequent problems.

Factors such as make and model of the phone, wireless carrier, calling area transmission, handset vs. speakerphone use, and general background noise from the road, home or social events all posed threats to accurate transmission of prescription information. This is especially true if a message is left on the pharmacy voice mail. If follow-up calls were needed for clarification, the pharmacist often did not have the physician's cell phone number. Also, since physicians often did not have access to the patient's medical records, they could not answer questions about allergies, weight, or other medications. Likewise, the medications prescribed were less likely to be documented in the patient's record, since it was not available. That could obviously cause problems later on, due to the missing medical information.

Most pharmacists reported difficulty recognizing the physician's voice on the phone and verifying their identity. Some reported that it was especially difficult when the consumer initiated the call to the physician while at the pharmacy counter. In many cases pharmacists will ask the prescriber to call the pharmacy back using an office phone line. For obvious reasons, many pharmacists will not accept certain prescriptions at all via a cell phone call that is initiated by a patient at the counter.

Because confidentiality cannot be assured, calls should never be made in the presence of others. Another problem cited in our survey was possible breach of patient confidentiality through inadvertent or purposeful eavesdropping from people close by or even through insecure cellular phone lines.

Although it may seem obvious, we recommend that physicians refrain from using cell phones for patient care purposes while in the office. Instead, they should communicate prescriptions using a landline, fax machine, electronically, or hand a prescription to the patient. If cell phones must be used out of the office, we advise pharmacists to have the prescriber spell the patient's name, drug name, and designate the dose clearly.

While I'm at it, let me remind you that you shouldn't be using a cell phone anyway when you come to the pharmacy to pick up your prescription. One pharmacist told us about a patient who was on the phone while picking up a prescription when he called out her name. "Is your last name Smith?" She answered yes, but wasn't really paying attention to the pharmacist at all. Instead it was a response to a question on the phone. The patient signed for the prescription and walked away with the wrong prescription bag. Conversational interaction can obviously be impaired when the patient is using a cell phone at the time of prescription counseling or purchase.

There is one thing you should do about your cell phone. In one case reported to us a patient was accidentally given another patient's medications. Later, when a pharmacist realized the mistake, he attempted to reach the patient by phone. However, the patient did not answer. The pharmacist kept trying but did not get through until later that evening. By that time, the patient had already taken medication for a kidney transplant patient who needed an immunosuppressant. Instead, she was supposed to be getting a new prescription for Zestril, for high blood pressure.

Pharmacists most often ask new patients for their home phone and maybe their business line, but not necessarily their cell phone numbers or email addresses. It makes sense to provide these other modes of contact for emergencies like the one described.

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