Problems related to verbal orders (including both orders given verbally in face-to-face encounters and those given via telephone) have received much attention from the Joint Commission, ISMP (ISMP 2001), and the Pennsylvania Patient Safety Authority (PPSA 2006) among others. A timely article surveying hospital policies on verbal orders appears in this month’s issue of The Joint Commission Journal on Quality and Patient Safety (Wakefield 2012). The Wakefield article highlights the extreme variability of verbal order policies across hospitals and even some inconsistencies within hospitals.
While we all have numerous anecdotal examples of adverse events related to verbal orders, there is actually almost no literature looking at verbal order-related errors from a larger perspective (Wakefield 2009). We all assume, based on common sense and our own anecdotal experiences, that verbal and telephone orders are more error-prone than written or computerized orders. Yet one of the only systematic studies addressing the issue (West 1994) failed to demonstrate that. In fact, in their study verbal orders were actually less error-prone than written or computerized orders!! They did note, however, that verbal orders became more prone to error as the orders became more complex.
Could the prior study showing that verbal orders are actually less error-prone (West 1994) have been true? There are at least some theoretical and practical reasons that verbal orders might, in fact, be less error-prone. A nurse transcribing orders does not have to decipher the handwriting of a physician on written orders. Similarly, the artifacts often seen with faxed orders (eg. “missing” decimal points, etc.) don’t come into play with verbal orders. And the nurse (or pharmacist) taking the verbal order has the opportunity to clarify the order more easily than with written orders. And the types of orders given verbally tend to be less complex. So maybe, despite our suspicions to the contrary, they could be less error-prone. That, of course, does not mean we should not have policies, procedures and practices for dealing with verbal/telephone orders to make sure that verbal/telephone orders are as safe as possible. We’d all like to think that with the widespread implementation of computerized physician order entry (CPOE) the need for verbal or telephone orders will be eliminated. That, however, is extremely unlikely. There are always likely to be situations in settings such as the OR, ER, ICU, sterile procedure rooms, etc. where a provider is tied up attending to one patient’s needs and an urgent order is needed on another patient. And even where we make CPOE available remotely to physicians not on site, there will be times when the systems are unavailable.
We all have our own examples of adverse patient events related to errors in the verbal/telephone order process. And the literature is replete with more examples: vitamin K being confused with potassium (Lesar 2003), morphine 2 mg IV misinterpreted as 10 mg IV (Koczmara 2006), 15 mg of hydralazine vs 50 mg IV (Koczmara 2006), Orgaran misinterpreted as argatroban (Koczmara 2006), azithromycin misinterpreted as erythromycin (PPSA 2006), Klonopin misinterpreted for clonidine (PPSA 2006), and multiple other examples.
There are lots of common sense reasons that verbal or telephone orders are vulnerable to error and misinterpretation. Accents and pronunciation are highly variable. There may be static on telephone lines. There may be considerable background noise on either end of a phone conversation (or even face-to-face verbal communication) that impedes communication.
“Covering” physicians may be relatively unfamiliar with the patient and not have access to the full medical information needed to prescribe medications (or order tests or procedures) safely. And we’ve previously talked about the chance of patient misidentification when orders are done remotely (see our Patient Safety Tips of the Week June 19, 2007 “Unintended Consequences of Technological Solutions” and May 20, 2008 “CPOE Unintended Consequences - Are Wrong Patient Erors More Common?”).
In many cases of verbal orders the ordering provider may be otherwise distracted (eg. they are busy attending to the urgent needs of another patient) or multi-tasking. Worse yet, in some of those scenarios the provider relays the verbal order via yet a third party (Lesar 2003).
And verbal or telephone orders are vulnerable to the same errors we see with look-alike sound-alike (LASA) drugs and dangerous abbreviations in written orders.
An especially vulnerable scenario occurs when a verbal or telephone order is taken by a nurse who not only transcribes the order but must then obtain the medication (eg. from an automated dispensing machine) and administer it to the patient without any other intervening safety steps. That is likely to happen at night in many hospitals when the physician is not in the hospital and pharmacists are unavailable.
About a year ago we were at a small hospital and observed a nurse taking a telephone order. We asked “How do you know who that was on the phone?”. The response was “We’re a small hospital. We know all the doctors’ voices.” But during our stay we noted numerous new nurses working, who obviously did not know all the doctors on staff. And it turned out that there was a continuous turnover of both ER physicians and hospitalists, so “new voices” appeared regularly. Imagine how this issue could be more complex in our larger teaching hospitals and academic medical centers where there is a constant turnover of housestaff. It turns out that very few hospitals have any formal mechanism in their “verbal order” policies for verification of the prescriber on telephone orders. In the recent Wakefield article (Wakefield 2012) only around 10% of the smaller and community hospitals had any such mechanism, whereas about 64% of academic medical centers had some sort of mechanism to verify the identity of the caller. The latter usually included callbacks to physician offices or use of physician identification numbers.
There have been reports (ISMP 2008) of several instances of fraudulent orders. In one a teenager who worked at the hospital who began answering pages to on-call residents. He issued orders for 6 patients (lab tests, oxygen orders, heparin orders) that were not caught right away because the orders were medically “appropriate”. Another case involved a friend of a patient with AIDS calling in a verbal order for insulin in apparent attempt to end that patient’s life. And another case where someone posing as a physician ordered enemas on six different patients.
The ISMP article suggests several things you can do to avoid such fraudulent telephone orders. If you don't recognize the caller, request his or her telephone number, verify it in the medical staff directory, and call the prescriber back to take the order. You can also verify a cell phone number with the prescriber's office staff or answering service. Another identification method is asking for a doctor-specific number such as medical records dictation number, but you'd need a list of these numbers to verify the caller's identity. If the caller doesn't provide a telephone number or you can't verify it, ask the individual to call back to speak to a nursing supervisor.
One key factor in errors related to verbal/telephone orders is the situation in which the orders are given. Frequently they are given in response to a request from nursing. The physician (or other provider to whom the request goes) is often busy with other activities when the request comes in so he/she is multitasking and may be distracted by the other activities. Moreover, he/she typically does not have full access to the patient’s medical record when the request comes in. So orders are often given without full consideration of the patient’s other medications, allergies, comorbidities, renal function, lab values, etc. The 2006 Pennsylvania Patient Safety Authority article (PPSA 2006) has very good descriptions of the contextual errors encountered in incidents reported to the Pennsylvania Patient Safety Reporting System.
And any time you are ordering remotely, even if you have access to the electronic medical record, you have the potential to make mistakes (see our Patient Safety Tips of the Week June 19, 2007 “Unintended Consequences of Technological Solutions” and May 20, 2008 “CPOE Unintended Consequences - Are Wrong Patient Erors More Common?”). Moreover, the 2-item patient identification rule we use throughout our systems is frequently violated with verbal/telephone orders. How often have you heard a nurse call a physician and say “I’m calling about Doris Jones, DOB 03/11/56”. We’ll bet never! The call is usually goes “I’m calling about Mrs. Jones in Room 712B”. That, of course, would be unacceptable if we were planning to do a procedure on that patient. But is it any less safe to order medications on that patient? Not really.
The excellent paper from ISMP Canada (Koczmara 2006) also includes a description of how communication is handled in other high risk industries, such as conversations between railroad engineers and railway traffic controllers.
Often the verbal/telephone order is initiated by a request from nursing staff to the provider. In such cases, nurses should use a structured format like SBAR when initiating the request and provide the appropriate context for the request. If the provider is not onsite or does not have access to the patient’s medical record, it is important that the nurse provide as much information about the patient as is relevant to the request. That may include information about the patient’s current medications, allergies, medical conditions, lab values, etc.
“Read back” is the most critical communication technique to be used in the verbal/telephone order process, just as it is in aviation or other high risk industries. In “read back” the recipient reads back the message as he/she has heard it and interpreted it. The person giving the order then confirms that such recording and interpretation of the order is correct. Because drug names and doses may be prone to misinterpretation, often special techniques must be used. The drug name should be spelled out, for example using military-like terms such as “C as in Charlie”, “A as in Alpha”, etc. Certain doses, particularly those including a “-teen” (such as 16) may be misunderstood as having a “-ty” (such as 60). So spelling out the dose may be appropriate (for example, “one-six”).
So here are the important things pertinent to verbal and telephone orders you need to ensure take place via your policies, procedures and practices:
· Define in your policies what constitutes verbal or telephone orders
· Limit verbal or telephone orders to those circumstances in which it is not feasible to have the provider perform written or computer-entry orders (eg. when the provider is otherwise engaged in an urgent procedure elsewhere or is not on site)
· Encourage use of computerized physician order entry (CPOE) whenever a provider has access to the electronic medical record, whether in hospital or remotely
· Some facilities recommend that orders be written and faxed when the provider is outside the facility. However, we have concerns about that, given the problems identified with faxed orders and fact that there are no studies comparing safety of faxed orders vs. verbal or telephone orders.
· Specify who may give verbal or telephone orders
· Specify who may receive verbal or telephone orders
· Consider mechanisms to verify the identity of providers giving telephone orders (see above ISMP recommendations)
· When possible, medication orders should be called in to a pharmacist rather than allowing the possibility of an intermediary person (eg. nurse) mistranscribing or otherwise miscommunicating the order to pharmacy
· Where possible (and especially when high risk medications like insulin, anticoagulant, or narcotics are involved) have a second authorized person listen in to confirm the verbal or telephone order
· Do not allow verbal or telephone orders for certain high risk medications, such as cancer chemotherapy agents
· Some organizations also do not allow verbal/telephone orders for non-formulary medications (but this restriction can be problematic in some facilities)
· If you usually require the ordering provider include a formula (eg. in pediatric dosing) when doing written or computerized order entry, have him/her also include the formula when doing verbal or telephone orders
· Always do “read back” to the ordering provider to confirm the orders are correct
· When giving verbal or telephone orders or doing “read back” when receiving such orders, always spell out doses (eg. “sixteen, one six” so that “16” is not misinterpreted as “60”)
· Especially when the drug names are relatively unfamiliar or are one of the known “sound alike” drug pairs, the ordering provider or the recipient during “read back” should spell out the drug name using “C as in Charlie”, “A as in Alpha”, etc.
· Make sure the order does not include any of the “do not use” abbreviations or other dangerous practices (like trailing zeroes) in your dangerous abbreviations policy (and we strongly recommend ISMP’s dangerous abbreviation list rather than the much briefer list from the Joint Commission that most hospitals use)
· Including the indication for the drug may help prevent ordering drugs that are not appropriate for the patient
· Try to provide context for the ordering provider (allergies, lab values, other medications, medical conditions, etc.)
· The recipient should sign, date and time the order and indicate that it was a verbal order or telephone order
· Ensure verbal or telephone orders are promptly signed by the ordering provider
· Audit your facility’s use of verbal and telephone orders (frequency, appropriateness, errors, etc.), provide feedback to all staff, and include this in your quality improvement program
BTW, texted orders are not acceptable under any circumstance (Joint Commission 2011)!
In addition to the questions addressed in the recent Wakefield article (Wakefield 2012) about verbal order policies, the 2006 PPSA article (PPSA 2006) has a Verbal Orders Toolkit, a checklist for assessing verbal orders policies, a sample policy for verbal/telephone orders, and an audit tool to use in your quality improvement activities.
And don’t just use some of these techniques for verbal/telephone orders. Some types of orders we often fail to consider being “verbal” are really in the same category. A very interesting study (Doyle 2006) on an academic pediatric unit assessed mediation errors. Typically orders were discussed on morning rounds and the interns later entered the orders. They found over 9% of all orders had errors (most often with doses but sometimes with other errors). So they changed their process so that the orders were input while the team was still rounding in the patient rooms and “read back” was used. The error rate after implementation of the new process dropped to zero!
Institute for Safe Medication Practices (ISMP). Instilling a measure of safety into those “whispering down the lane” verbal orders. Medication Safety Alert! Acute Care Edition 2001; 6(2): 1-2
Pennsylvania Patient Safety Authority (PPSA). Improving the Safety of Telephone or Verbal Orders. PA PSRS Patient Saf Advis 2006; 3(2): 1,3-7
Wakefield DS, Wakefield BJ, Despins L, et al. A Review of Verbal Orders Policies in Acute Care Hospitals. The Joint Commission Journal on Quality and Patient Safety 2012; 38(1): 24-33
Wakefield DS, Wakefield BJ. Are verbal orders a threat to patient safety? BMJ Qual Saf Health Care 2009; 18: 165-168
West DW, Levine S, Magram G, et al. Pediatric Medication Order Error Rates Related to the Mode of Order Transmission. Arch Pediatr Adolesc Med. 1994; 148(12): 1322-1326
Lessar TS. 40 of K. AHRQ Web M&M 2003; November 2003
Koczmara C, Jelincic V, Perri D. Communication of medication orders by telephone – “Writing it right”. CACCN 2006; 17(1): 20-24 Spring 2006
Institute for Safe Medication Practices (ISMP). Telephone orders. How do you know the caller is for real? ISMP Nurse Advise-ERR 2008; 6(7): 2 (July 2008)
The Joint Commission. Standards FAQ Details. Texting Orders. November 10, 2011.
Doyle E. To prevent ordering errors, one hospital is bringing “read backs” to the bedside. Cincinnati Children’s Hospital Medical Center found that the technique cut down on communication problems during rounds. Today’s Hospitalist 2006; October 2006