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Instilling a measure of safety into those "whispering down the lane" verbal orders

From the January 24, 2001 issue

PROBLEM: Verbal orders - orders that are spoken aloud in person or by telephone - offer more room for error than orders that are written or sent electronically. The interpretation of what someone else says is inherently problematic because of different accents, dialects, and pronunciations. Background noise, interruptions, and unfamiliar terminology often compound the problem. Once received, verbal orders must be transcribed as a written order, which adds complexity and risk to the ordering process. The only real record of the verbal order is in the memories of those involved. When the recipient records a verbal order, the prescriber assumes that the recipient understood correctly. No one except the prescriber, however, can verify that the recipient heard the message correctly. If a nurse receives a verbal order and subsequently calls it to the pharmacy, there is even more room for error. The pharmacist must rely on the accuracy of the nurse's written transcription of the order and the pronunciation when it is read to the pharmacist.

Sound-alike drug names also impact the accuracy of verbal orders. There are literally thousands of name pairs that can easily be misheard. For example, we have received scores of error reports where verbal orders for "Celebrex 100 mg PO" were misheard as "Cerebyx 100 mg PO." Drug names are not the only information prone to misinterpretation. Numbers are also easily misheard. For example, an emergency room physician verbally ordered "morphine 2 mg IV," but the nurse heard "morphine 10 mg IV" and the patient received a 10 mg injection and developed respiratory arrest. In another case, a physician called in an order for "15 mg" of hydralazine to be given IV every 2 hours. The nurse, thinking that he had said "50 mg," administered an overdose to the patient who developed tachycardia and had a significant drop in blood pressure.

SAFE PRACTICE RECOMMENDATIONS: Faxes, electronic mail, and point-of-care computerized prescriber order entry are reducing the need for verbal orders in non-emergent situations. However, it is very unlikely that they will ever be totally eliminated. Please distribute the following guidelines to nurses, pharmacists, and physicians in your facility to stimulate discussion. While we are aware that all of the suggestions may not be feasible in your organization, they can help you evaluate your current practices.

  • Prescribers must enunciate verbal orders clearly and the receiver should always repeat the order to the prescriber to avoid misinterpretation. This step is absolutely essential and should become habit even if the receiver is confident that he or she has initially heard the order correctly. As an extra check, either the prescriber or listener should spell unfamiliar drug names, using "T as in Tom," "C as in Charlie," and so forth. Pronounce each numerical digit separately, saying for example, "one six" instead of "sixteen" to avoid confusion with "sixty."
    • Ensure that the verbal order makes sense in the context of the patient's condition.
    • Have a second person listen to the verbal order whenever possible. If the person taking the message is inexperienced, this should be required.
    • Record the verbal order directly onto an order sheet in the patient's chart whenever possible. Transcription from a scrap of paper to the chart introduces another opportunity for error. Obtain the phone number in case it is necessary for follow-up questions.
    • The receiver should sign, date, time, and note the order according to procedure. The prescriber should verify and sign/date orders within a predetermined time frame.
    • Never use verbal orders as a routine method of order communication. For example, do not allow verbal orders when the prescriber is present and the patient's chart is available. Instead, they should be reserved for situations where it is difficult or impossible for hard copy or electronic order transmission (e.g., orders communicated during a sterile procedure, etc.).
    • Do not accept verbal orders for chemotherapy because of their complexity and potential for tragic errors. To the extent possible, ensure that laboratory studies are performed and available when prescribers are on site so that dose adjustments are not required after the prescriber has left the facility.
    • When telephone communication results in the need to prescribe medications or change drug therapy, ask the prescriber to hand write the orders and fax them to the facility when feasible instead of communicating the orders verbally.
    • Do not allow medication requests from nursing units to the pharmacy unless the order has been transcribed onto an order form and simultaneously faxed or otherwise seen by a pharmacist before the medication is dispensed.
    • Limit verbal orders to formulary drugs. The names of drugs unfamiliar to staff are more likely to be misheard and their uses and dosages may be less familiar.
    • Limit the number of personnel who may receive telephone orders to ensure familiarity with hospital guidelines and the ability to recognize the caller, which reduces the potential for fraudulent telephone orders (ISMP Medication Safety Alert! January 10, 2001).
    • Whenever possible, have a pharmacist receive all verbal orders for medications. Ensure a mechanism for pharmacists to transcribe the orders directly into the medical record.
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