/publications/issue/2003/2003-11/2003-11-7502

Instilling a Measure of Safety into Telephone and Verbal Orders

Author: Kate Kelly, PharmD, Editor, ISMP Medication Safety Alert! Community/Ambulatory Care Edition, and Allen J. Vaida, PharmD, FASHP, Executive Director, Institute for Safe Medication Practices

Problem

    Telephone orders and verbal orders (those given directly by 1 person in the presence of another person) may offer more room for error than orders that are handwritten or sent electronically. The interpretation of what someone else says is inherently problematic because of different accents, dialects, and pronunciations. Background noise, interruptions, and unfamiliar terminology often compound the problem. Once received, these orders must be transcribed as written orders?which adds complexity and risk to the ordering process. Unfortunately, the only real record of the verbal order is in the memories of those involved.

    If a physician?s staff member takes a verbal order from the physician and subsequently telephones it in to the pharmacy, there is even more room for error. The pharmacist must rely on the doctor?s staff member (who may not have a health care background), not only to accurately transcribe the verbal order, but also to relay it correctly by phone. This situation may be even more problematic if the order is left on a pharmacy?s voice-mail system, because the pharmacist is unable to ask for clarification or read back the order unless he or she calls the prescriber?s office.

    Sound-alike drug names also can lead to misunderstanding. There are literally thousands of name pairs that are easily confused. Here is just 1 example: During an office visit, a man asked his physician for something to relieve his allergy symptoms. The physician telephoned the patient?s pharmacy and ordered ?60 Allegra? (fexofenadine). After picking up the prescription, the patient called his physician to find out why he had been prescribed a drug that cost $450. The shocked physician called the pharmacy. The pharmacist had misheard the telephone order as ?60 Viagra? (sildenafil).

    Staff members in physician offices and pharmacies have tried to prevent this type of error by posting wall charts of sound-alike drug names. (An example is available online at www.usp.org/pdf/patientSafety/qr762001-03-01.pdf.) Although these charts are excellent educational tools, they usually do not help when an order is being given, because people tend to assume that what they hear is correct.

    Drug names are not the only information prone to misinterpretation. Numbers, especially those in the ?teens,? also are easily misheard (such as ?sixteen? heard as ?sixty?).

Safe Practice Recommendations

    Facsimiles, electronic mail, and computerized prescribing are reducing the number of telephone orders in nonemergent situations. It is very unlikely, however, that these orders will ever be totally eliminated. The following guidelines should help make receiving verbal and telephone orders safer at the practice site. Although not all of these suggestions may be feasible at a given pharmacy site, they can be helpful as pharmacists evaluate their current practices.