Do physicians comply with verbal orders policy?

Your ED has a policy that verbal orders are to be used in emergencies only — but a medical staff member routinely calls in telephone orders for patients. What do you do?

Although verbal orders have been identified as high-risk for many years, their use still is very common in EDs, says Christine B. Macaulay, RN, MSN, CEN, nursing practice specialist and former ED project coordinator/clinical nurse specialist at Children’s Hospital of Philadelphia.

"I can remember 20-plus years ago, as a new ED nurse, my preceptor saying Try not to take verbal orders, because mistakes can happen,’" she recalls. "EDs need clear policies regarding safe practices, and the nurse is the key to reinforcing the standard of care when a physician is resistant to writing orders in nonurgent cases."

To reduce use of verbal orders, do the following:

  • Insist on written orders when physicians are present.

At Community Medical Center’s ED in Missoula, MT, if the physician is physically present, they cannot give a verbal order, and nurses cannot accept these, says Steven D. Glow, RN, MSN, FNP, care flight nurse and adjunct assistant professor at the College of Nursing at Montana State University-Bozeman, Missoula Campus.

"The nurses have been handling the implementation of this policy by informing the physicians, I cannot accept a verbal order when you are present. Here is the chart so you can write it down,’" he says.

In trauma and code situations when verbal orders are given, nurses may write the order and read it back to the physician, but the physician must sign the documentation at the end of the event, says Glow.

Consistent practice by ED nurses made resistant physicians more compliant, he notes. "I believe consistency is the key," Glow says. "If physicians can play one nurse against the other, as in Nurse A always lets me give verbal orders,’ the policy breaks down."

  • Use a scripted approach.

Develop a list of sample responses for nurse to say when physicians give verbal orders, Macaulay advises. "The key is to have all staff approach the standard in a consistent, positive way," she says. For example, Macaulay recommends saying, "I will be glad to get that medication. Could you write the order on the medical record as I go for the med?"

  • Resolve conflicts with joint education.

At University of Utah Hospitals and Clinics in Salt Lake City, the medical director insisted that the ED couldn’t function without verbal orders and refused to enforce compliance, says Denna Collier, APRN, clinical nurse coordinator for the ED.

This was in direct conflict with requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements, Collier says. "While this issue was addressed, it was not in time to affect practice before our JCAHO survey," she says. "We were lucky that no verbal orders occurred while the surveyor was in the department."

The Joint Commission requires that you reduce use of verbal and telephone orders and implement a "read-back" process to verify verbal orders when they are used. To ensure compliance, hold a joint inservice with a representative from medicine and nursing, Collier recommends. "That person is then responsible for relaying information back to the department," she says. "The kicker here is that all involved parties must believe and support the chosen JCAHO educator."

  • Ask physicians to limit telephone orders.

"In nonteaching hospitals when a patient is admitted to the hospital, attendings may try to call in all the orders for the admission," says Macaulay. "In teaching facilities, this is less of a problem."

When admitting physicians at Community Medical Center attempt to call in admission orders, they are put on the phone with the ED physician, who writes the orders on the admission order form, reports Glow.

In Edward Hospital in Naperville, IL, telephone orders previously were taken by ED nurses at the request of the attending physician out of convenience, so they wouldn’t get a second call from the floor, reports Sharron Chivari, RN, APN-CNS, clinical leader of the ED. Now, attending physicians are asked to give only enough admitting orders to cover the patient until they make rounds, instead of orders for the next two or three days. "This has reduced the number of orders per patient significantly, thereby reducing potential errors."

Physicians were reminded that some orders may be routine for floor nurses, but unfamiliar to ED nurses, which increases the risk of errors. They also are asked to sign off on telephone orders when they first see the patient.

In the past, nurses were inconsistent with reading back telephone orders to clarify them, adds Chivari. To address this, a policy was implemented requiring nurses to read back every item that the physician orders, and physicians may not include blanket orders such as "continue all current medications taken at home." Instead, these orders must be specified individually.

"Our quality assurance monitors now reflect consistent compliance with our read-back policy for every order," Chivari reports. "I personally have had difficulty with some of the heavy accents of the physicians. For physicians I just can’t understand after repeating a couple of times, I ask them to spell the word. They may not like it, but it’s preferable to making a mistake."

Sources

For more information, contact:

  • Sharron Chivari, RN, APN-CNS, Clinical Leader, Emergency Department, Edward Hospital, Naperville, IL. Telephone: (630) 527-3000. E-mail: schivari@edward.org.
  • Denna Collier, APRN, Clinical Nurse Coordinator, University of Utah Hospitals and Clinics, Emergency Department, Salt Lake City, UT. Telephone: (801) 587-3838. E-mail: Denna.Collier@hsc.utah.edu.
  • Steven D. Glow, RN, MSN, FNP, Adjunct Assistant Professor, College of Nursing, Montana State University-Bozeman, Missoula Campus, Missoula, MT. Telephone: (406) 243-2536. E-mail: sglow@montana.edu.