Recommendations to Reduce Medication Errors Associated with Verbal Medication Orders and Prescriptions

Preamble

Verbal orders are those orders given by the physician or other providers with prescriptive authority to a licensed person who is authorized by organization¹ policy to receive and record verbal orders in accordance with law and regulation².  They are defined as including all telephone and face-to-face patient care orders that were (1) communicated verbally by an authorized prescriber (e.g., physician, physician assistant [PA], clinical pharmacist or advanced practice registered nurse [APRN], (2) received by a licensed individual authorized by the organization to received verbal orders (e.g., RN, pharmacists, respiratory therapist) who will record the order and read it back to the person providing the order, , and (3) cosigned or authenticated by the authorized prescriber at a subsequent time to validate the order³. 

The United States has reached an 59% use of electronic health records in acute care hospitals and with this change providers can now receive electronic alerts on drug interactions, drug duplications, drug allergies and maximum or minimum drug doses⁴. These drug safety alerts help to safeguard the prescribing of drugs at the time of prescribing, prior to transmitting prescriptions/medication orders to a pharmacy. Electronic health record systems provide the safest means of communicating a prescription/medication order to pharmacies. The use of verbal prescription or medication orders is becoming less common and should be used infrequently when electronic patient records are - available, such as the need for use by on-call providers or use in emergency care situations.

Recommendations

The National Coordinating Council on Medication Error Reporting and Prevention makes the following recommendations to reduce confusion pertaining to verbal orders and minimize medication errors:

1. Verbal communication of prescription or medication orders should be limited to urgent situations where immediate written or electronic communication is not feasible.
    
2. Healthcare organizations should establish policies and procedures that do the following:
   • Describe limitations or prohibitions on use of verbal orders.
   • Provide a mechanism to ensure validity/authenticity of the prescriber.
   • List the elements required for inclusion in a complete verbal order.
   • Describe situations in which verbal orders may be used.
   • List and define the individuals who may send and receive verbal orders.
   • Provide guidelines for clear and effective communication of verbal orders.
   • Employ read-back techniques for clarifying verbal orders.
      
3. Leaders of health care organizations should promote a culture in which it is acceptable, and strongly encouraged, for staff to question prescribers when there are any questions or disagreements about verbal orders. Questions about verbal orders should be resolved before the preparation, dispensing, or administration of the medication.
    
4. Verbal orders for antineoplastic agents should NOT be permitted under any circumstances. These medications are not administered in emergency or urgent situations, and they may have a narrow margin of safety.
    
5. Information that should be given in a verbal order include the following:
   • Name of patient
   • Age and weight of patient, when appropriate
   • Drug name
   • Dosage form (e.g., tablets, capsules, inhalants)
   • Exact strength ,dose or concentration
   • Dose, frequency, and route (including the dose basis for pediatric patients)
   • Quantity and/or duration
   • Purpose or indication (unless disclosure is considered inappropriate by the prescriber)
   • Specific instructions for use
   • Name of prescriber—and telephone number, when appropriate
   • Name of individual transmitting the order, if different from the prescriber
      
6. The content of verbal orders should be clearly communicated:
   • The name of the drug should be confirmed by one or more of the following:
     • Spelling
     • Providing both the brand and generic names of the medication
     • Providing the indication for use
     • To avoid confusion with spoken numbers, a dose such as 50 mg should be dictated as "fifty milligrams...five zero milligrams" to distinguish from "fifteen milligrams...one five milligrams."
     • To avoid confusion with drug-name modifiers, such as prefixes and suffixes, additional spelling-assistance methods should be used (e.g. S as in Sam, X as in X-ray).
     • Instructions for use should be provided without abbreviations. For example, "1 tab tid" should be communicated as, "Take/give one tablet three times daily."
     • The receiver of the order should write down the complete order, then read it back, and receive confirmation from the individual who gave the order except in situations such as a sterile environment and/or emergencies when stating back the order (without writing the order down first) with subsequent confirmation is acceptable.
        
7. All verbal orders should be immediately written and signed by the individual receiving the order indicating the author of the order.
    
8. Verbal orders should be documented in the patient's medical record, reviewed, and countersigned or authenticated by the prescriber in accordance with organizational policy.

¹ Healthcare organizations include community pharmacies, practitioners’ offices, hospitals, nursing homes, home care agencies, clinics, and others.

² The Joint Commission. Human Resources (CAMH/Hospitals). Use of Unlicensed Persons Acting as Scribes. May 18, 2011. Accessed January 14, 2014. http://www.jointcommission.org/mobile/standards_information/jcfaqdetail…. Accessed January 14, 2014.

3 Wakefield DS, Wakefield BJ. Are verbal orders a threat to patient safety? Qual Saf Health Care.
2009; 18(3):165–168.

4 ONC Data Brief ■ No. 16 ■ May 2014 Adoption of Electronic Health Record Systems among U.S. Non-federal Acute Care Hospitals: 2008-2013 assessed 4/2015

Actions/Decisions are those of the Council as a whole and may not reflect the views/positions of individual member organizations.

Revised May 1 2015