The Lost Faxes

When a patient is suspected of having cancer it is vital that the correct procedures are met to ensure that they are seen by the correct consultant / healthcare professional.

Every possible action will be taken to ensure that the referral letter will get to the consultant / healthcare professional at the hospital concerned as soon as it possibly can. Surgeries will have their own protocol of dealing with this situations.

Let me share a story on a referral letter that was never received at the hospital.


True Story

It was 6.00 on a Friday evening – the doctor had a patient in with him who he suspected had a mass – possible cancer. It was too late to phone through to the consultant’s secretary for an appointment and too late for a letter go out in the post that same evening – so the procedure was the doctor had to fax the letter through – something that was done on several occasions.

All of the receptionists knew the procedure.

The fax went – and the letter format went on the Monday in the normal post. Tuesday there was a call from the hospital asking why they letter had not been in fact faxed through on the Friday – the Doctor said it was – but the hospital said they had no record of receiving it.

I was asked to investigate what had actually happened.

I went and spoke to the receptionist that sent the fax. She was obviously concerned and upset that I had to speak to her about the incident – to her it looked like I was accusing her of not sending the fax – I soon put her fears at ease and explained that I had to find out what had actually happened.

This was one of those moments where I was pleased that we kept a printed receipt of every fax sent and this was attached to the fax and filed. We found the letter and the receipt was attached that confirmed that the fax as indeed sent – and no errors had occurred whilst it was sent.

I telephoned the hospital – they were adamant that they had never received it. We had the “proof” that the fax was indeed sent from our office. But the still said they had not received it.

I am pleased to say the patient was not put at any extra risk and was seen within the allocated timescale.

Some weeks later I received a similar call from the hospital – they were waiting on a fax coming through and they had not received it. I checked again with Reception that they had sent it and they had all the confirmation that the fax had been sent. This happened for a 3rd time and I started getting concerned. Something was not right.

The faxes had been sent by 3 different receptionists – all very competent receptionists I might add and ones that took pride in their work. All of the receptionists were long serving receptionists and had been at the surgery for some years. Each and every one of them was concerned about the incidents that had taken place.

I went along to see the supervisor at the outpatients department where the faxes were going. She I was as concerned as I was about what was happening. This is where I found it very useful to have a good working relationship with the hospital because I felt that I could go along and chat to the supervisor about the incident – at the end of the day we wanted to get this matter sorted out and make sure that it didn’t happen again. After all we both wanted the best possible outcome for the patient.

(see my blog on Communication between the Surgery and the Hospital. )

I asked her if we were the only surgery that this was happening with – she told me it was – they made me feel that for whatever reason the error was happening at our end – but I could not for the life of me work out WHY. Each fax had been sent and the receipt of that fax kept and attached to the fax sent – we got a print out from the fax machine to back that up and it confirmed that the faxes had in fact been sent.

So, I went back to the surgery. One by one I asked each of the receptionists to send a text fax through to the supervisor at the outpatients department – who was waiting at the other end for them.

After the third fax had been sent I phoned the supervisor – she said that they had not come through – she confirmed that they had received many others from other surgeries in the time I was with the girls sending ours. I was baffled. I had actually witnessed the faxes being sent through.

I called another receptionist in – I asked her to send the same test fax – she did and I straight away got a phone call from the supervisor to confirm she had received the test fax.

Then it dawned on me – I knew what was happening……………………….

We had recently had a new fax machine installed in the surgery. The old fax machine used to send faxes face down – this new fax machine sent faxes face up! Such a simple error to make but such a bit impact when it did.

They were actually sending blank pages through to the hospital as they were sending them upside down.

I telephoned and spoke to the Supervisor – I explained what had happened – she went into the fax office (the fax machine was in an office on its own and secretaries and administrators would pop in every so often to take the faxes off the machine) The supervisor confirmed there was in fact 3 blank sheets amongst all the other faxes waiting to be sorted. She agreed that the secretaries or administrators would have just thought they were blank pages that had just come through with other faxes.

So a simple thing like a new fax machine caused so many problems. The receptionists were mortified that they had made the mistakes – but said they were so used to using the old fax machine at times when they were so busy they just put them through as they would have normally.

So, I put a big notice over the fax machine that said

~Pease send fax facing UP!

A reminder email was sent out to everyone in the surgery including Doctors/Nurses/District Nurses/Health Visitors and other healthcare professionals who all at times used the fax machine.

That seemed to do the trick thank goodness. No more episodes of blank faxes.

So never take it for granted that a new member of staff can send a fax – always make sure that you run through the procedure with them – just in case!

I must admit I have never been a fan of fax machines!