Faxed Arabic prescriptions: a medication error waiting to happen?

Area of Science:

• Medical Informatics
• Linguistics
• Patient Safety

Background:

• Medical errors pose significant risks to patient safety.
• Existing research on prescription errors primarily focuses on handwritten or Roman-alphabet prescriptions.
• Little attention has been given to the risks associated with reproducing prescriptions in non-Roman scripts, especially those with diacritical marks.

Purpose of the Study:

• To investigate the potential for errors in Arabic diacritical marks when prescriptions are reproduced via fax.
• To assess the impact of fax transmission on the legibility and accuracy of critical medical instructions in Arabic.

Main Methods:

• Generated common prescribing instructions in both English and Arabic, including diacritical marks.
• Used various font sizes and printed them on standard prescription paper.
• Reproduced the documents using fax machines at two different medical facilities.

Main Results:

• Fax compression algorithms and transmission noise significantly altered the appearance of Arabic diacritical marks.
• These alterations introduced stochastic noise and dropouts, leading to misinterpretation of the original instructions.
• A demonstrated example showed a potentially dangerous change in prescribing information due to fax-induced errors.

Conclusions:

• Faxing prescriptions in languages with diacritical marks, like Arabic, presents a high risk of misreading.
• Fax-induced degradation of diacritical marks can lead to critical medication errors.
• Mitigation strategies, such as optimizing font size and using alternative text formats, are recommended to improve faxed prescription safety.