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
- 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
- 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.