Every year, thousands of patients in hospitals and clinics across the U.S. and Australia are harmed because someone misheard a medication order. Not because the doctor was careless, but because the system let them down. Verbal prescriptions - those quick, spoken orders given during emergencies, surgeries, or shift changes - are still part of daily care. But they’re also one of the most dangerous steps in the entire process. The good news? We know exactly how to make them safer. And it’s not about eliminating them. It’s about doing them right.
Why Verbal Prescriptions Still Exist
You might think electronic prescribing made verbal orders obsolete. But that’s not true. In operating rooms, trauma bays, and during rapid patient transfers, there’s no time to log into a computer. A surgeon needs to tell the nurse, "Give 10 milligrams of epinephrine IV now." A nurse in the ER has to confirm a dose of insulin before a diabetic patient goes into surgery. These aren’t convenience choices - they’re life-or-death necessities. According to the Agency for Healthcare Research and Quality, verbal orders still make up 10-15% of all medication orders in hospitals. In emergency departments, that number jumps to 25-30%. Even with CPOE systems in place, there are moments when typing isn’t fast enough. The key isn’t to ban them. It’s to control them.The Real Danger: Sound-Alike, Look-Alike Drugs
The biggest risk in verbal prescriptions isn’t bad handwriting. It’s bad hearing. Take these pairs:- Celebrex vs. Celexa - one’s for arthritis, the other for depression
- Zyprexa vs. Zyrtec - one’s an antipsychotic, the other an allergy pill
- Hydralazine vs. Hydroxyzine - one lowers blood pressure, the other treats anxiety
Read-Back: The One Rule That Saves Lives
There’s one practice that cuts verbal order errors in half. It’s not new. It’s not fancy. It’s just simple: read-back verification. Here’s how it works:- The prescriber gives the full order: "Give 5 milligrams of morphine IV every 4 hours for pain."
- The receiver repeats it back exactly: "Five milligrams of morphine IV every four hours for pain."
- The prescriber confirms: "Correct."
Numbers, Units, and the Two-Method Rule
A dose isn’t just "10." It’s "10 milligrams." Or "10 micrograms." The difference could kill someone. The Institute for Safe Medication Practices Canada says to say numbers two ways. For example:- "Fifteen milligrams. That’s one-five milligrams."
- "Two point five milligrams. That’s two and a half."
High-Alert Medications: When Verbal Orders Are Forbidden
Some drugs are too dangerous to order verbally - unless it’s a true emergency. The Pennsylvania Patient Safety Authority and Washington State Department of Health explicitly ban verbal orders for:- Chemotherapy (except to hold or discontinue)
- Insulin
- Heparin
- Opioids like morphine, fentanyl, oxycodone
Documentation: The Only Record That Matters
The only real record of a verbal order? The paper or screen it’s written on. Memories fade. People change shifts. Someone forgets. That’s why CMS and The Joint Commission require immediate transcription into the electronic health record. The order must include:- Patient’s full name and date of birth
- Medication name (spelled out)
- Dose with units (e.g., 5 mg, not just 5)
- Route (oral, IV, IM, etc.)
- Frequency (e.g., every 6 hours)
- Indication (why it’s being given - e.g., "for chest pain")
- Name and credentials of the prescriber
- Time and date the order was given
- Time and date it was authenticated
Who Can Enter the Order?
In 2022, CMS updated its rules to allow authorized documentation assistants - like nurses or medical assistants - to enter verbal orders into the EHR at the prescriber’s direction. But here’s the catch: only the prescriber can authenticate it. That means a nurse can type it in, but the doctor must review and sign off. No exceptions. No shortcuts. This isn’t about bureaucracy. It’s about accountability.
What to Do When Something Feels Off
You’re on the phone. The prescriber says, "Give 100 units of insulin." You pause. That’s not right. The patient’s blood sugar is normal. You don’t have a recent order for insulin. Don’t give it. Don’t ask, "Are you sure?" Ask, "Can you please confirm the dose and reason? I want to make sure I’m not missing something." Nurses on AllNurses.com report that asking for clarification has prevented multiple near-misses. One nurse said spelling out "hydralazine" as "H-Y-D-R-A-L-A-Z-I-N-E" stopped a 10-fold dosing error. Another said asking for the indication - "Why are we giving this?" - revealed the order was meant for a different patient. Trust your gut. If it feels wrong, it probably is.How to Build a Culture of Safety
No single rule fixes everything. Safety comes from culture. Hospitals that succeed with verbal prescriptions do three things:- Train everyone - doctors, nurses, aides - on the exact protocol. Not once. Every year.
- Use standardized scripts. "I’m giving a verbal order for [medication]. I’ll spell it out: [A-M-P-I-C-I-L-L-I-N]. Dose is [5 mg]. Route is IV. Frequency is every 6 hours. Indication is sepsis. Prescriber is Dr. Lee."
- Call out violations - respectfully. If a doctor skips read-back, say, "I need to hear it back to make sure I got it right." Make it normal. Make it expected.
What’s Next? The Future of Verbal Orders
Voice recognition tech is getting better. By 2025, KLAS Research predicts verbal orders will drop to 5-8% of total orders. But experts like Dr. Robert Wachter say some situations will always need spoken communication. Surgery. Trauma. Rural clinics with no internet. That means safety protocols aren’t going away. They’re becoming even more critical. The FDA is working on standardizing how high-risk drug names are pronounced. States are passing laws to make read-back mandatory. And hospitals are training staff to treat every verbal order like a ticking time bomb - because it is. The bottom line? Verbal prescriptions aren’t going to vanish. But they don’t have to be dangerous. With clear rules, disciplined practice, and a culture that values verification over speed, we can make them safe.Are verbal prescriptions still allowed in hospitals?
Yes. Verbal prescriptions are still permitted under CMS and The Joint Commission regulations, especially in emergencies, operating rooms, and during rapid patient transfers. However, they must follow strict safety protocols, including mandatory read-back verification and immediate documentation in the electronic health record.
What’s the biggest cause of errors in verbal prescriptions?
The biggest cause is sound-alike drug names. Medications like Celebrex and Celexa, or Hydralazine and Hydroxyzine, are frequently confused when spoken. This accounts for 34% of verbal order errors, according to the Institute for Safe Medication Practices. Always spell out drug names letter by letter to prevent these mistakes.
Is read-back verification really necessary?
Yes. Read-back verification - where the receiver repeats the order back to the prescriber - is mandatory under The Joint Commission standards and has been shown to reduce medication errors by up to 50%. Skipping it increases the risk of deadly mistakes. If you don’t hear it back, don’t assume it’s done.
Can you give verbal orders for insulin or heparin?
Only in true emergencies. Insulin, heparin, opioids, and chemotherapy are classified as high-alert medications. Most hospitals and state health departments prohibit verbal orders for these drugs unless the patient’s life is immediately at risk. Even then, a second healthcare provider must verify the dose before administration.
What should be included in the documentation of a verbal order?
Every verbal order must be documented immediately in the electronic health record and include: patient name and date of birth, medication name (spelled out), exact dose with units, route of administration, frequency, indication for use, prescriber’s name and credentials, time and date the order was given, and time and date it was authenticated by the prescriber.
Can a nurse enter a verbal order into the EHR?
Yes, but only under direct direction from the prescriber. A nurse or medical assistant can type the order into the system, but the prescriber must personally review and authenticate it. No one else can sign off on it. This ensures accountability and prevents unauthorized changes.
How can I improve safety when taking verbal orders?
Follow these steps: 1) Spell out every drug name. 2) Say numbers two ways (e.g., "fifteen milligrams, one-five milligrams"). 3) Never use abbreviations. 4) Always do read-back. 5) Document immediately. 6) Ask for clarification if anything feels off. 7) Speak up if protocols aren’t followed. Your vigilance can prevent a mistake.
