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.

 

 

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

 

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.⁴

 

 

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 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

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