Does this sound familiar? A physician calls with telephone orders for one of your patients. It’s one of “those” days. The nurses’ station is frantic with activity and noise. Other phones are ringing, people are at the desk asking questions, admissions are coming in, discharges are waiting to go home, and here you are trying to get critical information from a physician over the phone.
This was probably one of the scenarios that The Joint Commission
had in mind when it addressed effective verbal/telephone communication between healthcare providers in its National Patient Safety Goals
.Almost 100,000 people in the United States die each year as a result of medical errors,1
and ineffective communication, including on the telephone, contributes significantly to these errors. In fact, The Joint Commission has described communication problems as the No.1 cause of sentinel events, the unexpected incidents that result in death or serious, permanent injury to a patient — or the risk of such harm (a “near miss”).
The National Patient Safety Goals have included a category on communication in healthcare ever since their introduction in 2003. The communication goal started out with two safety measures: the read back of verbal/telephone orders and the use of standard abbreviations. In 2005, The Joint Commission added a third item, the timely and accurate reporting of critical lab results, and in 2006, a fourth, a requirement for standardizing “handoff” communications. All these requirements continue in 2012 although verbal/telephone orders, standard abbreviations and handoff communication have become Joint Commission standards and have moved from the category of National Patient Safety Goal.2 From taking an order over the phone to handing off a patient to another department, all healthcare professionals face situations involving potential communication problems every day. Healthcare professionals must understand and adopt safety practices to ensure the smooth functioning of the healthcare team — and the safety and optimal care of their patients.
What Did You Say?
Verbal or telephone orders are a significant source of medical errors. Errors can occur not only in the scene described above at the nurses’ station, but also when the person giving an order is difficult to understand. Think about all the accents, dialects and pronunciation patterns heard in almost any hospital these days — and how orders could be misinterpreted, leading to a medical error. Other dangers of telephone or verbal communication are interruptions, distractions, unfamiliar drug names or terminology, medications with sound-alike names and reliance on memory when writing down an order at a later time.3 All are recipes for disaster.
Another consideration is the speed with which verbal or telephone orders are carried out. Actions resulting from verbal and telephone orders usually occur right away, giving little time for correction if the person taking the order noted it erroneously. With verbal or telephone orders, the person giving the order has a natural tendency to expect that the person taking the order will understand it and copy it accurately into the medical record. But even if the person taking the order understands it, he or she may make an error in transcribing it.
As part of its National Patient Safety Goals, The Joint Commission requires the person receiving a verbal or telephone order to write down the complete order or enter it into a computer as it’s being given, then read it back and receive confirmation from the person who gave the order. This ensures the accurate transcription of all verbal or telephone orders, not just the more common medication orders. The read-back process also applies to critical test results, which will be covered later. In emergencies, such as a code or during surgery in the OR, this read-back process may not be possible. In this case, a “repeat back” is acceptable.2,3
The best way to prevent errors resulting from verbal or telephone orders is to limit their use.2 But this is easier said than done. It’s much easier for the provider to give a verbal or telephone order than to write it in the medical record. The Joint Commission suggests that organizations make the written process as easy as possible. Organizations have done this in various ways, including using preprinted order sheets with check boxes or having providers fax written orders if they aren’t onsite. Organizations fortunate enough to have computerized physician order entry may use handheld computers or easy-access terminals to make it convenient for providers to electronically enter their orders.2
The Joint Commission makes these additional suggestions to improve the verbal/telephone order process and ensure safety:3
- Ask the provider for the correct spelling of a medication if you are unsure.
- When repeating an order back to the provider, spell out numbers, e.g., 17 would be one — seven.
- Avoid using abbreviations. For example, “1 tab t.i.d.” should be stated as “Give one tablet three times daily.”
- Have a second person listen to the verbal/telephone order whenever possible, especially if an inexperienced healthcare professional is taking the order.
- Record a verbal order directly onto the physician order sheet. This eliminates transcription as a source of error.
- Limit the number of people who are allowed to receive verbal orders and be sure they are familiar with the verbal/telephone order policy.
- Restrict the use of verbal/telephone orders in certain areas, e.g., oncology, where chemotherapeutic drugs are involved. Any drugs that are high risk and have complicated or sound-alike names should not be prescribed verbally.
- Write the purpose of the drug on the order. The order should also include the drug name, dosage form, strength of concentration, frequency, route, quantity and duration.
Employees should take verbal/telephone orders only for things that are within their scope of practice, e.g., a ward clerk should not take a practitioner’s verbal order for patient-related issues.
Read back does make a difference. One study examined what happened when residents entered verbal orders from attending physicians into bedside computer terminals during rounds. At first, the study found that 9.1% of the entries were in error, mostly in drug dosages. In the second part of the study, before leaving a patient’s room the residents read back the order that they had entered into the computer. The attending physician or chief resident then verified its accuracy. With the read back added, the error rate fell to zero.
Another source of medication errors is dose designations that include decimal points. For example: A patient gets 10 times the normal dose of a medication because the nurse did not see the decimal point in the “1.0” written by the physician, or an order for “.1 mg” is interpreted as “1 mg” because the nurse doesn’t see the decimal point.
Overdoses can easily result from using a trailing zero when none is needed, e.g., 1.0 mg instead of 1 mg, or failing to use a leading zero when writing a fractionated dose, e.g., .1 mg instead of 0.1 mg. All these are real-life errors that could happen at any time.
The Joint Commission’s National Patient Safety Goals require facilities to have a standardized list of “do-not-use” abbreviations to include the following dose designations, abbreviations, acronyms and symbols:
- The abbreviations “U” and “IU,” which can easily be mistaken for the number “0,” especially when the “U” is written too closely to the number. For example, a patient could receive 60 units of insulin because the nurse interprets “6U” as “60.” Or “IU” could be misinterpreted as “IV” or the number “10.” The safest way is to write out “unit” and “international unit.”
- The abbreviation “q.d.” (every day), which can be read as “q.i.d.” (four times a day), especially if the period after the “q” or the tail of the “q” is misunderstood. Writing out “every day” will eliminate this error. Similarly, the abbreviation “q.o.d.” (every other day) can be seen as “q.d.” or “q.i.d.” if the “o” is poorly written. The correct form here is to write out “every other day.”
- The last of The Joint Commission mandates on abbreviations relates to magnesium sulfate (MgSO4) and morphine sulfate (MSO4). When MgSO4 and MSO4 are written hastily, they can easily be confused. Write out magnesium sulfate and morphine sulfate so there can be no mistake as to which is intended.5
The Joint Commission recommendations on abbreviations have been difficult to enforce, largely because of ingrained behavior. Changing the order practices of physicians who have been writing orders the same way for 10, 20 or 30 years is challenging. The same can be said of clinicians and other professionals who take physicians’ orders verbally or telephonically and use nonstandard abbreviations on the order sheet or when transcribing orders to the medication administration record. The Joint Commission asked accredited hospitals how they handle the dangerous abbreviation issue. Several suggestions are below:6
- Print an authorized abbreviation list at the top or bottom of order sheets or in the margins.
- Provide physicians and staff with pocket-size, laminated abbreviations cards with a hole on top so they can be hung with ID cards.
- Print an abbreviation list and laminate it to the physician orders section chart divider.
- Review all preprinted order forms and modify as necessary.
- Educate, monitor and provide feedback to physicians and staff who document in the medical record.
- Make dangerous abbreviations (and all National Patient Safety Goals) an agenda item at all medical staff department/section meetings.
- Run articles in physician and employee newsletters about “do-not-use” abbreviations.
Another approach is having the pharmacy refuse orders that contain prohibited abbreviations. The order must be corrected with the proper abbreviation before the pharmacy processes it. Nurses and other healthcare professionals can play a part by notifying the prescribing physician before the order is sent to the pharmacy. But some physicians have become so upset with “prohibited abbreviation” calls that they have refused to change orders or answer the phone or their pager. The upshot is a delay in the patient’s medication.7
The bottom line is to focus on the elimination of prohibited, error-prone abbreviations as a systemwide concern, not one just for healthcare professionals including nurses, pharmacy staff or physicians. To create a culture of safety regarding abbreviations, hospital and medical staff leadership needs to promote educational efforts, physician “champions” must support the initiative, and clinicians must encourage their peers to adhere to the program. This must be a “physician-owned” process to enforce physician compliance.7