Jennifer Nopoulos MSNEd, RN, CPAN
Verbal and telephone orders communicated from a provider to a RN have long been acceptable, necessary, and precarious. Several factors contribute to error, including sound-alike medication names, background commotion, telephone connection quality, and language barriers (Wakefield & Wakefield, 2009, & Shastay, 2019). Computerized provider order entry (CPOE) became widely available over a decade ago, leading to an expectation of a decrease in verbal orders, but surveys and experience reveal that the practice and its vulnerabilities persist (Shastay, 2019). Verbal and telephone orders are a necessity for emergent situations, or if the provider is in another procedure or without electronic access (Wakefield & Wakefield, 2009). These situations directly apply to nurses in the peri-operative theater, so what guidelines and limits should our facilities put in place to safeguard our patients and ourselves?
Although there is little evidence of patient harm resulting from verbal orders, there are many case reports documenting error (Kaplan et.al., 2006). Almost every peri-op RN has an example of a miscommunication with a provider during their practice. Authors identify common drugs involved in errors, including antihistamines, analgesics, antipyretics, blood pressure medications, and antiemetics, which are the most common medications used in the post-operative setting (Kaplan et.al. 2006, & Shastay, 2019). The Joint Commission has advocated for reducing or even eliminating the use of verbal orders (Wakefield & Wakefield, 2009), but is this realistic in peri-operative units?
According to Wakefield & Wakefield (2009), verbal orders are still used when the provider is either “unable or unwilling” to use CPOE. (pg. 165). Many providers use verbal orders as a convenience, not limiting their use to appropriate necessity. A common example of this would be the anesthesiologist who supplements their report with additional verbal orders, increasing the chances of an error as the PACU RN is appropriately focused on the patient’s initial assessment. Wakefield & Wakefield (2009) acknowledge that receiving and entering verbal orders increases the RN’s workload, and care priorities must be considered. An additional concern would be from whom the order is given. Telephone orders can be passed through a provider’s staff member or other unlicensed designee which can place the receiving RN who carries out the order in legal jeopardy (Wakefield et.al., 2012).
Wakefield et.al. (2012) confirms that some facilities have enacted policies which prohibit verbal orders, but for peri-operative personnel, this hard prohibition would not be welcome or adequate. Shastay (2019) recommends limiting verbal orders to only when the provider cannot enter them. Do not allow verbal orders to routinely be used for provider convenience, or to avoid learning to use the EMR. If the provider is present, they, (or their designee) should enter the order themselves, avoiding face to face verbal orders except in the setting of emergent interventions (Wakefield et.al., 2012). When receiving verbal orders, clarify by avoiding abbreviations, using the phonetic alphabet (alpha, bravo, etc.), and using the most important strategy, the read back practice safeguard (Shastay, 2019).
Finally, I would add a warning to PACU staff who accept an anesthesiologist’s “give whatever you want, I’ll sign it later” type of verbal order. Although this is cloaked in what we perceive as autonomy and respect, it is not in an RN’s scope of practice to prescribe, the anesthesiologist may refuse to sign for what you have given, and it may be just the provider’s indolence instead of a welcome compliment. To assist the providers, it is helpful to have resources immediately available to instruct those who are unfamiliar with the EMR system, providing timely entry of necessary peri-operative orders.
References
Kaplan, J.M., Ancheta, R., & Jacobs, B.R. (2006). Inpatient verbal orders and the impact of computerized Provider order entry. Journal of Pediatrics, 461-7, doi: 10.1016/j.jpeds.2006.05.038
Shastay, A. (2019). Despite technology, verbal orders persist, read back is not widespread, and errors continue. Home Healthcare Now, Jul/Aug2019; 37(4): 230-233. doi: 10.1097/NHH.0000000000000799
Wakefield, D.S., & Wakefield, B.J. (2009). Are verbal orders a threat to patient safety?
Qual Saf Health Care. Jun;18(3):165-8. doi: 10.1136/qshc.2009.034041.PMID 19467996
Wakefield, D.S., Wakefield, B.J., Despins, L., Brandt, J., Davis, W., Clements, K., & Steinmann, W.
(2012). A review of verbal order policies in acute care hospitals. Joint Commission Journal on
Quality & Patient Safety, 2012 Jan; 38(1): 24-33. doi: 10.1016/s1553-7250(12)38004-5