Orders communicated verbally are common in all clinical settings with estimates as high as 20% of all inpatient ordering. Do you use verbal orders in your correctional facility? I’m confident that you do…..and probably more frequently than traditional settings, as prescribers are often less accessible in our secure environment.
A Verbal Order (VO) has the following characteristics:
- communicated orally by telephone, digital device, or face-to-face
- requires transcription by an approved individual
- requires the prescriber to follow-up with review and signature of the transcribed order
The most common verbal order errors involve misinterpretation of the dose or the medication name. For example, verbal order errors reported in the literature include misinterpreting the number fifteen (15) as being fifty (50) and the number two (2) as being ten (10). Besides dosage confusion, sound-alike medications have also caused verbal order errors. Examples cited include mistaking azithromycin for erythromycin and Klonopin for clonidine.
Verbal information among care providers can also lead to error. Verbal communication of blood glucose readings without confirmation have resulted in administration of overdoses of insulin, as when the nurse heard a verbal report of the patient’s blood glucose reading being 353 when the reading was actually reported as 85.
Repeat That Please
For these reasons, patient safety experts recommend a standing policy that all verbal orders be read back to the prescriber before implementation. Besides verbal orders, this state-back policy should include high-risk clinical information that results in medication administration such as blood glucose levels or patient assessment information during a code.
One pediatric hospital reduced verbal order errors from 9% to zero by implementing this process. The read-back process requires the staff member who receives a verbal order to read-back the order information and obtain affirmation from the prescriber that the information is accurate. The read-back process includes the following components:
The receiving staff member writes down the order as it is verbalized by the prescriber.
- The receiving staff member repeats the order back to the prescriber – reading directly from the written dictation.
- To reduce sound-alike errors in medication and dosage, the reader spells out the medication name and dosage amount, for example, t-w-o – 2 mg.
- A verbal affirmation is obtained from the prescriber before initiating the order.
- A second staff member qualified to accept verbal orders listen in on highly risky communications such as insulin, anticoagulants, and narcotics
Who is speaking?
We are surprisingly trusting when taking patient orders by phone. One study found that few smaller institutions asked for identification when prescribers called with patient orders. With the rapid turnover of staff and covering providers, it can be risky to rely on voice recognition to confirm identification. Many large academic institutions use provider identification numbers for verbal orders. Several incidents of individuals posing as providers have fooled staff into taking and implementing verbal orders for patients. Although we usually know our providers, and in fact, nurses typically initiate the call to a provider, the correctional setting does offer an opportunity for outsiders to use telephone communication for the benefit of their incarcerated friend/loved one. Be sure that you know who is on the other end of the line when you accept verbal orders.
Know Your Limits
The high risk of error with verbal orders requires limits on use. Here are some standard limits placed on verbal orders that should be considered in our setting:
- Limit verbal orders to urgent patient care needs and not as a routine practice or for convenience purposes,, unless you are a small site that does not have a provider onsite daily.
- Limit the number of staff who can take verbal orders.
- Limit the type of medication that can be ordered to formulary medications that are more likely to be familiar to staff members.
- Do not use verbal orders for complex medication schemes such as chemotherapy.
What is your practice regarding verbal orders? Share your thoughts and tips in the comments section of this post.