Blog » Medication Instructions and Texts: A Dangerous Interaction

Medication Instructions and Texts: A Dangerous Interaction

Created Feb 02 2018, 06:17 PM by Lippincott Solutions
  • medication safety
  • mobile technology
  • medication errors
  • patient safety

The Institute for Safe Medication Practices (ISMP) is warning hospitals, outpatient centers, and long-term care facilities to stop allowing clinicians to use text messaging to communicate medication orders.

This, after:

  • a rapid response team had to be activated and naloxone administered to an older adult who experienced significant respiratory depression after a controlled substance dose was increased via a texted order. The texted order was actually intended for a different, younger patient but lacked unique patient identifiers, which led to the error. 
  • a patient was dispensed the wrong medication because a device’s autocorrect feature changed the drug name.
  • a busy hospitalist texted a medication order for the wrong patient. Noticing the order didn’t seem correct, a pharmacist clarified the order and discovered the error.

These are just a few real-world examples of errors and close calls uncovered during a recent survey of ISMP newsletter readers. Of the 742 US nurses, pharmacists, physicians, and others who responded to the survey, 7% were aware of errors or close calls involving texted orders.


“The texting of medication-specific orders should not be allowed until the safety issues have been identified and resolved through advanced technology along with the development of vetted, industry-wide clinical guidelines that can be employed in organizations to ensure standardized, safe, and secure texting processes,” the institute stated in a November 2017 safety alert announcing the findings.

“Leadership must establish and communicate policies on the texting of orders and take a strong stance on avoiding texted medication-specific orders at this time until they can be safely introduced into healthcare through careful pilot testing and implementation plans.”

According to the survey respondents, more than half work in facilities with policies that prohibit the texting of medical orders. Yet 35% of nurses and 45% of pharmacists report the regularly texting of medical orders despite facility policy.

Among respondents who said they’ve received texted orders over the past year, more than half did so daily or weekly.


Nurses, along with medication/patient safety officers and risk/quality managers, tended to be more concerned about the risks of texted orders. Physicians, the ISMP reported, were the least concerned.

The top 5 concerns of respondents were:

  • unintended autocorrection of medical terms, abbreviations, or drug and patient names;
  • the use of confusing abbreviated terminology in texts, such as “2day” for today, “b/4” for before, and “MT” for empty (According to 1 respondent, the abbreviation “BTW” [by the way] was interpreted as a typo in a texted order and mistaken for “BID” [twice daily] for a medication dosing frequency.);
  • patient misidentification;
  • misspellings; and
  • incomplete orders.

Other areas of concern were failures to document text messages and an inability to authenticate the sender or receiver.


Not everyone who responded to the survey was opposed to texted of medical orders. The ISMP reported that numerous respondents said that while it may not be as safe as electronic prescribing, they consider texted orders no riskier than verbal or phone orders.

Plus, it’s quicker.

“We disagree,” the ISMP countered, “particularly given that verbal or telephone orders can be read back to ensure accuracy and understanding, and because most practitioners who responded to our survey are texting orders via standard cell phones or devices without encryption or critically important safety features.”

It continued, “While other forms of communicating medical orders carry some of the same risks as texting orders, the informal nature of texting orders, often without a known policy or procedure associated with the process, has resulted in uniquely alarming risks, including abbreviated language, improper autocorrection, and texting orders without full patient names and a second unique identifier to offset some data security concerns, to name a few.”

Does your facility have a policy against texted orders? Is it followed? Leave us a comment.  


If your organization is looking for additional resources to prevent medication administration errors, let Lippincott Advisor help! Our industry-leading bedside decision support software for hospitals contains over 17,000 evidence-based monographs and patient teaching handouts, including a robust program set specifically on Drugs with thousands of entries that feature the latest updates and guidelines for use.  

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