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Verbal Orders Can Communicate Trouble

Monday July 2, 2007
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Verbal orders — those spoken aloud in person or by telephone — offer more room for error than orders that are written or sent electronically. Once received, a verbal order must be transcribed as a written order, which adds complexity and risk to the ordering process. The only real record of a verbal order is in the memories of those involved.

The Pennsylvania Patient Safety Reporting System (PA-PSRS) and other organizations have compiled reports of medical errors caused by verbal orders. A review of these reports indicates that when a nurse relays a verbal order to the pharmacist, the risk of error is even greater. The pharmacist must rely on the accuracy of the nurse’s written transcription of the order and the nurse’s pronunciation of the drug’s name.

Contributing factors

Issues that affect the accuracy of verbal orders and contribute to medical errors include the following —

    • Sound-alike drug names. There have been numerous reports submitted to PA-PSRS in which drug names were misheard, resulting in administration of the wrong medications. For example, in one instance a misheard verbal order led to a patient receiving Klonopin (a brand-name for clonazepam, an anticonvulsant) instead of clonidine (an antihypertensive).

    • Misinterpreted numbers. In one report submitted to PA-PSRS, an emergency room nurse thought a physician had stated a patient was to receive “1 and 1/2 teaspoons” of Zithromax, which was given. The written order indicated the dose was 1/2 teaspoon. In a similar case reported to the Institute for Safe Medication Practices (ISMP), an ER physician verbally ordered “hydralazine 15 mg IV,” but the nurse heard “hydralazine 50 mg IV,” according to the January 24, 2002, Medication Safety Alert! issued by ISMP.

    • Verbal communication of multiple medications at the same time. While awaiting transfer of a premature baby girl to a nearby children’s hospital, a physician gave a verbal order to administer ampicillin 200 mg and gentamicin 5 mg IV push. According to the same issue of Medication Safety Alert!, the nurse misheard the second antibiotic order as gentamicin 500 mg.

    • Verbal communication of a patient’s lab values. Many of the reports submitted to PA-PSRS citing this type of error involved misinterpretation of blood sugar levels for patients on insulin therapy. For example, a nursing assistant verbally told a nurse a patient’s Accu-Chek results. The nurse misinterpreted what she was told and based insulin coverage on a falsely high blood sugar, so the patient received four units of insulin when no insulin was needed.

    • Breakdowns in the communication of relevant patient information. Such information includes medication lists, diagnoses, comorbidities, and allergies. When the normal pharmacy check systems are not in place (for example, medications are available in unit stock or the pharmacy is closed but accessible by nonpharmacy staff), errors can result.


Safety initiatives

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has a national patient safety goal to address the error-prone procedures of verbal orders. The goal states that the recipient of a verbal or telephone order should write down the complete order or enter it into a computer while the physician is still on the phone and then read it back and receive confirmation from the individual who gave the information.

A study conducted at Cincinnati Children’s Hospital Medical Center found that orders given verbally without use of the read-back procedure had a 9% error rate. After implementation of a read-back procedure, the verbal order error rate dropped to zero, according to a presentation of the study made at the Pediatric Academic Societies annual meeting in April 2006.

Safe practices

The following are some safe practices that might be feasible for hospital (see “Verbal Order Toolkit Available,” below, for information about additional safe practices and other resources) —

    • Limit verbal communication of prescription or medication orders to urgent situations in which immediate written or electronic communication is not feasible.

    • Write down the complete order or enter it into a computer, read it back, and receive confirmation from the person who gave the order.

    • Include the purpose of the drug in all medication orders to ensure that the order makes sense in the context of the patient’s condition.

    • Include the mg/kg dose and the patient’s specific dose for all verbal neonatal/pediatric medication orders.

    • Ensure that medication doses are expressed in units of weight (mg, g, mEq, mMol).

    • Have a second person listen to a verbal order whenever possible.

    • Record verbal orders directly onto an order sheet in patient’s chart.

    • Disallow verbal requests for medications from nursing units to the pharmacy, unless the verbal order has been transcribed onto an order form and simultaneously faxed or otherwise seen by a pharmacist before medication is dispensed.

    • Limit verbal orders to formulary drugs.

    • Limit the number of personnel who may receive telephone orders to help ensure familiarity with facility guidelines and the ability to recognize the caller, according to the Jan. 24, 2002, Medication Safety Alert!

    • Have a pharmacist take verbal orders for medications whenever possible.

    • Raise awareness about problematic drug name pairs at your facility so practitioners are prepared to challenge questionable orders as they are received, according to the November 2003 Medication Safety Alert! Community and Ambulatory Edition.



Matthew Grissinger, RPh, is a clinical analyst, and Jesse Munn is the production editor for the Pennsylvania Patient Safety Reporting System.

Editor’s Note: This article is an abridged version of an article that first appeared in the June 2006 issue of the PA-PSRS Patient Safety Advisory, with permission of the Pennsylvania Patient Safety Authority.

Verbal Orders Toolkit Available

Visit the Pennsylvania Patient Safety Authority (PSA) website at www.psa.state.pa.us to obtain a safety toolkit that includes the following —
    • The source article, “Improving the Safety of Telephone or Verbal Orders,” from the June 2006 PA-PSRS Patient Safety Advisory
    • A poster that discusses the read-back procedure
    • A sample policy on verbal orders
    • A copy of the survey, “Sample Assessment Questionnaire on Verbal Orders,” which is customizable to your facility
    • A brief PowerPoint slideshow with audio narration on safe practices related to verbal orders• •

    To view or download any of the resources from this toolkit, click on “Advisories and Related Resources” in the lefthand column of the PSA home page. Then click on “Resources Associated with Patient Safety Articles.”