For best quality, send only original orders to pharmacies.

Vol. 34 No. 5 • May 2009 • P&T® 227 Interestingly, one of the features of document-imaging technology—the ability to magnify the order image—might actually be contributing to the problem. Although magnification can sometimes be helpful, it should not be necessary when clearly written original documents are scanned. However, magnification has become somewhat of a crutch or a work around for barely legible orders, whether the cause is indecipherable handwriting or a lack of clarity associated with scanned copies of orders. The solution seems obvious; the original order should always be scanned. So why does the problem persist in some hospitals? A few practitioners have told us at ISMP that nurses and unit secretaries do not like to remove the original order from the patient’s chart because they are concerned they will forget to return it or that they will place it in the wrong chart. This worry may be especially prevalent if unit secretaries are unavailable to assist nurses or if the scanning device or fax machine is not located right next to the person who is transcribing the orders. Several practitioners have also told us that nurses or unit secretaries might be minimizing the problem because they are not aware of the extent and scope of errors that have resulted from faxing and scanning copies of orders. Pharmacists might also be unaware of workflow barriers that make it difficult for nurses and secretaries to scan or fax the original order. Using the NCR copy might simply be the result of longstanding habits that developed when previous systems were in place to communicate orders to the pharmacy. Copies of orders, which used to be sent to pharmacies by courier or tube, are no longer necessary if the original order can be scanned or faxed to the pharmacy. The continued use of multipage NCR order forms, especially with the advent of scanning or faxing technology, is a prime example of a failure to evaluate the effects of the new technology on the presMr. Grissinger is Director of Error Reporting Pro grams at the Institute for Safe Medication Practices in Horsham, PA (www. ismp.org). For Best Quality, Send Only Original Orders to Pharmacies