Shared on behalf of Quality and Risk Management
Quality & Risk Management has been alerted to incidents involving faxed patient referrals that were not received by the intended recipients despite appearing to have been successfully transmitted. This presents potential patient safety risk by delaying patient follow-up or diagnostic assessments and treatment planning. Information Technology (IT) has investigated potential technological causes; however, concerns have persisted.
Effective immediately, when fax is used to transmit patient-care information, particularly referrals, the following mitigation measures are required.
- Prior to transmission:
a. All faxes must be sent using the organization-approved fax cover sheet. The staff member sending the fax must include the names of both the sender and the intended recipient. The approved fax cover sheet can be found on the iNtranet: https://informed.tbrhsc.net/departments/communications-andengagement/branding,-logos-and-templates.
b. Whenever possible, use the pre-programmed Address Book on the fax machine. Departments are responsible for verifying pre-programmed fax numbers at least bi-annually. If a fax number must be entered manually, the individual entering the number must verify the recipient’s fax number on the fax machine prior to starting the transmission.
c. Ensure a fax confirmation report is generated. If the fax machine does not automatically produce one, select the option to print a confirmation report before sending.
2. Following transmission:
a. Document transmission of the referral using the fax stamp, including the initials of the individual who sent the fax and the date and time of transmission.
b. Where possible, notify the intended recipient/program through an established communication method that a referral has been transmitted by fax. Do not include personal health information unless using an approved secure method.
c. For urgent or critical referrals, contact the intended recipient/program directly to confirm receipt of the referral.
Important: A successful fax confirmation indicates that the transmission was completed; it should not be relied upon as confirmation that the referral was received or actioned by the intended recipient.
3. If a fax is sent to an incorrect fax number:
Follow the appropriate steps above to resend the fax to the correct recipient. Notify the Privacy Officer of the misdirected fax by emailing TBRHSC.Privacy@tbh.net.
4. When receiving faxes:
When removing documents from a fax machine, verify the documents were intended for your department.
If a misdirected fax is received:
- Notify the sender of the fax received in error.
- The sender should notify the Privacy Officer.
- Confirm with the sender whether the misdirected fax should be securely destroyed or returned to the sender by interoffice mail.
- Do not forward the fax to the intended recipient.
Thank you for your cooperation in implementing these additional safeguards to support timely
communication and reduce the risk of delays in patient care associated with misdirected or
unreceived faxes.
