View as “PDF version”
It’s well accepted that verbal orders or telephone orders are potentially prone to error. That’s why we always recommend avoiding them whenever possible. But sometimes use of such orders is unavoidable, such as when the clinician is in the OR or attending to an emergency in a different area. Unfortunately, the current COVID-19 pandemic has created circumstances where there has been an increased need to provide orders verbally or via telephone. When the ordering clinician is offsite we still recommend he/she use CPOE whenever possible (via remote access). Orders given via CPOE make use of proper terminology, use clinical decision support tools, and typically remind the clinician of all parameters needed for a proper order.
But when there is no alternative, it’s important to ensure that both the ordering clinician and the receiving party (nurse, pharmacist, etc.) properly convey all the elements of the verbal or telephone order.
ISMP Canada (ISMP Canada 2020) recently published a safety bulletin on safety issues with telephone or verbal orders. That bulletin begins with a report about a miscommunication in a telephone order for hydromorphone that led to dispensing of the oral liquid formulation instead of the intended injectable formulation. The oral product was injected by a home care nurse, which resulted in harm to the patient.
ISMP Canada reminds us to allow sufficient time to state the order clearly and for the person receiving it to read it back. The ordering clinician should state his/her name, license number, and contact information. Say and then spell out the patient’s name and provide a second identifier (e.g., address, birth date). Note that the ordering clinician should have some way of knowing the patient’s full name and second identifier. But there is some important information the ordering clinician may not have readily at hand, such as the patient’s allergies, the patient’s weight, and the full list of the other medications the patient is taking. The person receiving the verbal order may have access to that information and provide it to the ordering clinician.
Next, incorporate all the elements of a complete medication order, including drug name, dosage form, dose and strength (if applicable), route of administration, directions for use, and quantity to be dispensed and/or duration of therapy. For prescriptions that are given to community pharmacies, also provide the number of refills and/or the refill interval.
Two extremely important concepts for verbal or telephone orders are: spell out and read back. ISMP Canada recommends drug names be communicated by first saying and then spelling them out. Both the generic and brand names should be provided, especially for recognized look-alike, sound-alike medication pairs. It may be helpful to use a phonetic alphabet to distinguish between sound-alike letters (e.g., “m” as in Mary or “n” as in Nancy). Numbers should be communicated using two different approaches. For example, because the number 15 can easily be misheard as 50, a prescription for “15 mg” should also be communicated as “one-five-milligrams”.
Abbreviations should be avoided. For example, replace “BID” with “twice a day”, and replace “PO” with “by mouth” or “orally”. They also noted that the patient’s weight should be included for pediatric patients and for all weight-based medication orders.
“Read back” is arguably the most important facet of any verbal or telephone order. The person receiving the order reads back the entire order, slowly and distinctly. The same techniques described above for using a phonetic alphabet to distinguish between sound-alike letters and specifying numbers one digit at a time should be adhered to. The receiver should then request confirmation from the prescriber that the read-back matches the intended order. Any ambiguous aspects of the prescription or order should be clarified by both.
The ISMP Canada guideline emphasizes a point we harp on over and over – providing the indication for a medication is a very useful safety tool. See our August 2019 What's New in the Patient Safety World column “Including Indications for Medications: We Are Failing” for a discussion of that issue. ISMP Canada says you should explicitly state the indication for the drug, to reduce the risk of misinterpretation.
ISMP Canada notes you should obtain the prescriber’s name, license number, and contact information at the start of the call. We do like the ISMP Canada requirement of obtaining the contact information of the ordering clinician. It’s critical that staff know how to get hold of that clinician in the event that questions about the order arise following the initial phone call.
They recommend the order be immediately transcribed or entered into its permanent record (e.g., patient chart, pharmacy hard copy and/or profile) to facilitate accurate documentation of the prescription. Delaying this documentation step can contribute to erroneous transcription. ISMP in the US has also recommended verbal orders should be immediately transcribed into the patient’s medical record or onto a prescription pad as they are being communicated (ISMP 2017). They note that transcription from scrap paper to the medical record introduces another opportunity for error. But they note there may be challenges to directly entering verbal orders into an electronic health record. When a nurse or pharmacist is allowed to enter such orders into the EMR, we recommend that the ordering clinician remain available as those orders are entered, since there may be alerts or other clinical decision supports that pop up during order entry that need to be addressed. For order clarifications by a pharmacist, a mechanism should be provided for the pharmacist to transcribe the orders directly into the patient’s medical record.
The person receiving the telephone or verbal order, of course, needs to be someone whose scope of practice allows them to receive orders. Your bylaws and rules and regulations should clearly spell out who can receive these orders and what types of orders they can receive. Usually the receiver is a nurse or pharmacist. But there might be some types of orders that could be received by a respiratory therapist or physical therapist or others.
Most hospitals are woefully inadequate regarding security measures for telephone orders. After we’ve witnessed a nurse taking a telephone order, we often ask that nurse “How did you know who was giving you that order?”. The usual response is “Well, I know his/her voice.”
We use at least 2-factor identification for patients. Why wouldn’t we demand at least that much for identification of a clinician providing a telephone order? The ISMP Canada bulletin suggests obtaining the ordering clinician’s name and license number (as well as contact information) at the start of a call. We don’t like using the license number. It is too easy to find that license number. Someone posing as that clinician can usually find his/her license number either online at the state health department website or from the license/registration that many states require be posted in the clinician’s office. An alternative is for each hospital to assign a special code (akin to the PIN you use at ATM’s) to each clinician for use in such phone calls. (It would be more difficult to assign codes for each community pharmacy given that a clinician is likely to have patients using many different pharmacies.)
In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we note 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 suggested 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.
Are there some orders that should be “off limits” for telephone orders? You’ve heard us tell the story about the resident who ordered (from his oncall room) a neuromuscular blocking agent for a patient, not realizing that the patient was not intubated and being mechanically ventilated. There could be unintended consequences of totally barring such orders but you could, at a minimum, require that certain orders (eg. for NMBA’s, opiates, etc.) would require a second person verify the order. You probably should prohibit verbal or telephone orders for chemotherapy (other than those to hold or discontinue chemotherapy) because these are seldom emergent and the complex dosing of such medications makes them even more error-prone (ISMP 2017). ISMP also recommends limiting verbal/telephone orders to formulary drugs (ISMP 2017). That’s because the names and dosages of drugs unfamiliar to practitioners are more likely to be misheard.
The ISMP Canada bulletin is not the only recent one reminding us of the dangers of verbal and telephone orders. In our April 2020 What's New in the Patient Safety World column “More Gems from ISMP” we noted ISMP’s Top 10 Medication Errors and Hazards for 2020 (ISMP 2020). Number 4 on that list is “Misheard drug orders/recommendations during verbal/telephone communication”. It recommended reserving verbal or telephone orders for use only during an emergency or when the provider is working in a sterile environment. It noted the importance, when verbal orders are necessary under those conditions, the receiver should READ BACK (or repeat back during sterile procedures) the drug therapy (drug, dose, route, frequency), SPELLING the drug name, and stating the dose in single digits (e.g., one-five for 15).
A 2017 survey by ISMP had some disturbing findings (ISMP 2017). While most verbal orders were given via telephone or face-to-face, there were instances of verbal orders being left on voicemail. And respondents noted that up to 25-50% of orders were verbal orders! Nearly half (45%) of all respondents who reported receiving telephone or spoken orders said they do readback less than 50% of the time. 16% of respondents said they read back verbal orders only 1-5% of the time, and 9% indicated they never carry out this important verification process. 14% of respondents were aware of an error that occurred in the past year due to mishearing, misunderstanding, or incorrectly transcribing verbal orders
In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we listed the important things pertinent to verbal and telephone orders you need to ensure take place via your policies, procedures and practices. They are still, remarkably, applicable:
That last point is important. If your audit finds that there is an unacceptably high frequency of verbal or telephone orders in your organization, you need to find out why. For example, in a previous column we noted a hospital found a very high percentage of transfusion orders were being given as verbal orders. When analyzed, it became apparent that the order entry process for transfusions was so onerous that it was easier for the ordering clinician to just do a verbal order.
In our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders” we mentioned one of the only systematic studies addressing the issue (West 1994) failed to demonstrate that that verbal orders were more error-prone. In fact, in that 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 that 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.
Of course, that brings us to another of our annual rants: don’t text orders! And we don’t like faxed orders! See our many columns on texted orders and faxed orders listed below.
See our other Patient Safety Tip of the Week columns dealing with texting:
· January 28, 2020 “Dang Those Cell Phones!”
See our prior columns on problems related to use of fax in healthcare:
ISMP (Institute for Safe Medication Practices). Despite Technology, Verbal Orders Persist, Read Back is Not Widespread, and Errors Continue. ISMP Medication Safety Alert! Acute Care Edition 2017; May 18, 2017
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)
ISMP (Institute for Safe Medication Practices). Start the New Year Off Right by Preventing These Top 10 Medication Errors and Hazards. ISMP 2020; January 16, 2020
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
Print “PDF version”