Avoid Verbal Orders

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A nurse caring for an 18-month-old child in the emergency department received a verbal order from a resident as he walked out of the department: “Give the kid point 8 of morphine.” The resident intended for the child to receive morphine sulfate, 0.8 mg, but the nurse, thinking in milliliters, instead used a syringe of morphine packaged as 10 mg/mL and administered 0.8 mL or 8 mg of morphine to the child. The child went into respiratory arrest and unfortunately was not able to be resuscitated.¹ This tragic story is a perfect example of why verbal orders should not be routinely accepted, even when a physician is present, and why medications orders should be complete, indicating actual dose by mg (not volume), route, frequency, and indication.

Verbal orders have long been a “way of life” in the emergency department and are used routinely as a method of communication, especially for everyday, nonurgent needs. At the Institute for Safe Medication Practices (ISMP), we have learned from the error reports that we receive through the United States Pharmacopeia-ISMP Medication Error Reporting Program that verbal orders often cause miscommunications that result in medication error and thus should be used as little as possible. Yet, there are some circumstances in emergency departments, such as codes, trauma, and sterile procedures, in which the use of verbal orders cannot be avoided entirely.

The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) has identified verbal orders as potentially error prone and thus has encouraged practitioners through the National Patient Safety Goals to “improve the effectiveness of communication.” According to JCAHO, organizations need to “implement a process for taking verbal or telephone orders or critical test results that requires a verification or ‘read-back' of the entire order or test result by the person receiving the order or test result.”² JCAHO also recognizes that it cannot mandate the elimination of all verbal orders; rather, they use the term “minimize” in their new Medication Management Standards to allow for specific times when verbal orders cannot be avoided.³ Policies in your organization should address this fact: that verbal orders, when practitioners are standing face to face, should only be used when absolutely necessary, such as during emergencies or when the physician is working under sterile conditions and cannot write. Telephone orders, although troublesome because of the auditory component, are a necessary evil in today's mobile society.

ED nurses can take steps to prevent error with verbal/telephone order communication, such as the use of preprinted order protocols or the use of fax transmission. Some emergency departments have a strong policy against the use of any verbal orders for medication, unless under designated circumstances. Others have established restrictions on certain high-alert medications that should never be given based on a verbal or telephone order, such as thrombolytics or heparin products. ED administrators/unit managers need to support policies such as these that limit the use of verbal orders for the benefit of patient safety and simultaneously provide the resources necessary for alternative methods of communication.

“…implement a process for taking verbal or telephone orders or critical test results that requires a verification or ‘read-back' of the entire order.”

A single verbal order can result in serious error to a patient. Below are some recommendations to to minimize errors when verbal/telephone orders must be used. Adopt these safety practices within your department to help reduce the associated risks.

Prescribers can:

Listeners/receivers can:

ED nurses are especially vulnerable to errors resulting from verbal orders just by the nature of our practice, but all ED team members need to work together to ensure safe communication. This may take a big change in the culture of your emergency department; however, most practitioners are willing to make that sacrifice because the stakes are so high.

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References 

1. USP-ISMP Medication Error Reporting Program. Reports received 1971-present. Huntington Valley (PA): Author.
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2. Joint Commission on Accreditation of Healthcare Organizations. National patient safety goals [online] [accessed 2003 Nov 17]. Available from: URL: http://www.jcaho.org/accredited+organizations/patient+safety/04+npsg/facts+about+the+04+npsg.htm.
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3. Joint Commission on Accreditation of Healthcare Organizations. Medication management (prepublication copy) (draft copy edited for Hospital Manual 2003 Apr 2). Chicago; The Commission; 2003.
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4. In:  Cohen M editors. Medication errors. Washington (DC): American Pharmaceutical Association; 1999;
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Further reading 

• * ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: ismpinfo@ismp.org or call (800) FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.