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Reduce the risks of verbal orders with these steps
Verbal orders can put patients in danger for serious adverse outcomes resulting from medication errors, and the ED is at especially high risk for this, says Lisa DiMarco, RN, BSN, MBA, administrative director for emergency services at Edward Hospital in Naperville, IL. "Unlike other departments, verbal orders are common in the ED — out of both habit and necessity."
You can radically improve the safety of verbal orders by doing the following:
According to the Joint Commission’s National Patient Safety Goals, verbal or telephone orders or telephonic reports of critical test results must be verified by having the person receiving the order or test result read back the complete order or test result.
At Tallahassee (FL) Memorial HealthCare, orders are written and read back to the physician, except in dire emergencies such as resuscitation, major trauma, life- or limb-threatening events, says Debora Lee, RN, assistant director of the hospital’s Bixler Emergency Center. "It has been emphasized to all staff to be extra vigilant with verbal orders. This is a huge patient safety issue."
In a life-threatening situation, such as a cardiac arrest, the writing step is eliminated and the order is simply repeated to ensure clarity, says DiMarco.
"It is our practice that verbal orders are to be accepted only in an emergency, when life, limb, or eye is compromised or threatened," says Sylvie Simpson, RN, an ED nurse clinician at Orlando (FL) Regional Healthcare. "All other verbal orders must be followed with a written order for nursing to initiate them."
At Harford Memorial Hospital in Havre de Grace, MD, it was common for nurses to request an order and then write it for the physician, but physicians are now expected to write their own orders, says Barb Baughman, RN, director of emergency services. "We also had to work with the private attendings in the ED," she says. "The rule became: If you are in the ED, you need to write it."
Still, the ED ends up with many telephone orders for inpatients admitted through the ED, which make up about 70% of admissions. In order to obtain written orders, attending physicians are contacted before patients are transported to inpatient units, says Baughman. "We remind them they can fax the order to us. The idea is that we will take verbal orders, but it should be the last resort," she says.
A "pre-chart" order sheet is used in Edward Hospital’s ED when a patient is in the treatment area but a chart is not available yet. Staff members write down orders on the sheet at the time the physician calls out the order, says DiMarco. The form uses a checklist format for commonly ordered diagnostic studies with a space to record the time ordered. (See Pre-Chart Order Sheet.)
The physician or nurse writes the patient’s name on the pre-chart, since labels are not yet available. The nurse calls back the order after it is written, and the physician signs the pre-chart. This order form becomes part of the ED medical record. It is not used for subsequent orders if the normal ED record is available, reports DiMarco.
"We have had very good compliance with this process from the ED physicians and nurses," she says.
This process was implemented for unit clerks who receive verbal orders from physicians, such as orders to page a particular attending or to order a specific test for laboratory or X-ray, says DiMarco.
Many times, the physician would ask to have an attending physician paged, but the page was never returned because the unit clerk had not heard the request or the incorrect physician was paged, she notes. Another common problem was a physician writing an order for a lab or X-ray but getting no acknowledgment from the unit clerk, says DiMarco.
"The intent of the new check-back process is that the physician knows the unit clerk heard what was asked, and that any necessary clarification can be made at the time of the order," she says. "This is new, and we are managing the process to ensure there is compliance."
At Orlando Regional’s ED, protocols were revised to include more standing orders with the goal of reducing verbal ordering for standard interventions, says Simpson. "This helps you to define orders for patients who have not been diagnosed yet, and it also decreases turnaround times when initiated at onset of care."
Currently, an electronic documentation system is being developed at Orlando Regional’s ED to allow private physicians to enter orders for nursing from outside the hospital, reports Simpson. "The philosophy is that physicians should be responsible for effectively communicating their orders to nursing," she says.
At Harford Memorial, a monthly safety goal audit that includes verbal orders is done on the ED.
"We either do direct observation or ask what the procedure is for verbal and telephone orders, and score units for a correct answer," says Baughman. "Completing these audits allows us to target those who are noncompliant, and this is included on their annual evaluation."
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