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Pharmacists Say Cell Phones Contribute to Harmful Medication Errors

David W. Hodges
Partner at Kennedy Hodges LLP practicing pharmacy error, medical malpractice and personal injury law
Posted on May 25, 2012

While cell phones have been known to save lives in an emergency, a doctor on his or her cell phone can cause a harmful or even deadly sound-alike medication error. 

In a recent poll, over 40 percent of pharmacists said that they had experienced a “case of bad cellular” when receiving prescription orders over cell phones. The quality of cell phone calls, transcription problems and other factors combined to make cell phone orders a significant cause of medication errors.

Pharmacists noted that poor transmission and failed connections requiring callbacks were frequent problems. Many additional factors, including the make and model of the phone, different wireless carriers, speakerphone use and increased background noise all posed threats to the accuracy of prescription information. 

In the course of the poll, researchers found that physicians were more likely to call in orders on cell phones after office hours, on weekends, while in cars, or at social events. In these cases, doctors were also more likely to be hurrying, or not giving the prescribing task their full attention for some other reason. 

Several of these calls caused problems when they were left on the pharmacy voicemail. Orders left by cellphone were more likely to need follow-up calls for clarification--difficult since many pharmacists do not have access to physician’s cell phone numbers. This caused problems on the doctor’s end as well; the prescriptions were less likely to be noted in the patient’s medical record since it was not available at the time of the call. 

Finally, pharmacists reported difficulty verifying the physician’s identity due to poor call quality. Many of the pharmacy staff were encouraged to ask the prescriber to call the pharmacy back using an office phone line. 

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