0. Improving the Safety of Verbal and Telephone Orders
PA - PSRS
Improving the Safety of Verbal and Telephone Orders
Hello, and thank you for joining us. My name is Matt Grissinger. This presentation addresses the hazards associated with verbal orders and steps you can take to make these orders safer. The information presented here is based on the work of the Pennsylvania Patient Safety Reporting System, or PA-PSRS. The Powerpoint slides for this presentation are available on the web site of the Pennsylvania Patient Safety Authority, which is responsible for PA-PSRS.
Matthew Grissinger, R.Ph.
Patient Safety Analyst
PA Patient Safety Reporting System (PA-PSRS)
June 2006

1. What’s wrong with verbal orders?
Verbal orders present more room for error than written or electronic orders
Communication difficulties:
Different accents, dialects, pronunciations
Background noise, interruptions
Unfamiliar drug names and terminology
Adds more steps to prescribing and transcription processes
Verbal orders—those that are spoken aloud in person or by telephone—offer more room for error than orders that are written or sent electronically. Interpreting speech is inherently problematic because of different accents, dialects, and pronunciations. Background noise, interruptions, and unfamiliar drug names and terminology often compound the problem. Verbal orders also involves several additional steps in the prescribing and transcriptions processes, introducing more opportunities for error.

2. What’s wrong with verbal orders?
Only record is in the minds of the people involved.
Only the prescriber can verify that an order was heard correctly.
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 the prescriber and the order recipient.
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.

3. Types of problems reported to PA-PSRS
Wrong drug: verbal order for clonidine misheard as Klonopin
Wrong dose: Toradol 15 mg misheard as 50 mg
Wrong lab results: Blood sugar misheard as 257 when it was 157, and patient received 6 units regular insulin instead of 2 units.
The types of problems that have been reported to PA-PSRS by Pennsylvania healthcare facilities include:
Wrong drug: For example, in one case a nurse mistook a verbal order for Klonopin (an anti-seizure medication) when the intended medication was clonidine (an anti-hypertensive)
Wrong dose errors have also been reported, even with high-alert medications. For instance, one hospital reported a phone order mistaken for Toradol --an opioid analgesic– at 50 mg, which was administered prior to the pharmacy review, when the intended dose was 15 mg.
Errors have also occurred when caregivers took action in response to misinterpreted test results, as happened in a case where a nurse misheard the patient's blood sugar as 257 when it was actually 157. The patient was given 6 units regular insulin instead of 2 units regular insulin.

4. What can you do to prevent errors?
JCAHO National Patient Safety Goal
Read-back procedure
Cincinnati Children’s Hospital reduced their errors with verbal orders from 9% to zero by using the read-back. Source: Vossmeyer MT. Improving patient safety using a verbal order read back process. Pediatric Academic Societies Annual Meeting; 2006 Apr 29; San Francisco (CA).
WRITE it down
READ it back
get CONFIRMation
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has established a National Patient Safety Goal to address the error-prone procedure of verbal orders. The goal states that the receiver of the verbal or telephone order should write down the complete order or enter it into a computer, then read it back, and receive confirmation from the individual who gave the order or test result.
Physicians at Cincinnati Children’s Hospital Medical Center studied error rates associated with verbal orders, with and without the read-back procedure, during physician rounding. They found that orders given verbally without the read-back had a 9% error rate. By implementing the read-back procedure, they reduced their verbal order error rate to zero. This added only seconds to each visit to a patient’s room, so it did not slow physician rounding.

5. What can you do to prevent errors?
Discuss the indication for medication orders
Discuss allergies, lab values, diagnoses
Express drug doses by unit of weight
Record verbal orders directly onto an order sheet
If you receive verbal orders via voice mail, contact the provider for read-back and confirmation
Make it a habit to discuss the indication when giving or taking verbal medication orders. Since most sound-alike drugs have different indications, this provides an opporunity to catch an error before it occurs.
For prescribers, ask for important patient information when giving a verbal medication order, such as drug allergies, lab values and diagnosis or comorbid conditions that may effect the prescribed medications.
Express drug doses by unit of weight (e.g., mg, g, mEq, mMol). Verbal orders that specify the dose in terms of the number of tablets, ampuls, or vials, and orders that state a volume without also expressing the concentration, have led to errors and even serious patient injury because many medications are often available in several package sizes and strengths.
Recording the verbal order directly onto an order sheet in the patient’s chart. Transcription from scrap paper to the chart introduces another opportunity for error. Phone or pager numbers can be helpful in case it is necessary for follow-up questions.
Since voice mail does not allow for a read-back procedure, this is not a good method of communicating verbal orders. If you receive verbal orders by voice mail, contact the provider in real-time and get confirmation using the read-back.

6. What can you do to prevent errors?
Prescriber review and verification
Use only approved abbreviations
Verbal orders for chemotherapy are unsafe
Prescribers should verify and sign verbal orders within the timeframe determined by their facility. Many reported errors associated with verbal orders were discovered when reviewing written documentation of the order.
Use only approved abbreviations when communicating or documenting verbal orders.
Because of the increased risk of harm from misinterpreted chemotherapy orders, and since they are not used on an emergency basis, verbal chemotherapy orders are considered unsafe. 

7. http://www.psa.state.pa.us For More Information
This presentation was based on the following article:
Improving the Safety of Verbal and Telephone Orders
PA-PSRS Patient Safety Advisory. June 2006—Vol. 3, No. 2
Thank you for joining us for this presentation. We hope you’ll find this information useful in your own facility.
This presentation was developed as part of the Pennsylvania Patient Safety Reporting System. To learn more about PA-PSRS and to find information on other topics, visit the Patient Safety Authority Web site at
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