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National Coordinating Council Recommends Ways to Reduce Verbal Order Errors Council Suggest Limits, Elements to be Included in Verbal Orders May 21, 2001 Rockville, MD — At its most recent meeting, the National Coordinating Council for Medication Error Reporting and Prevention (Council) identified a set of recommendations to help reduce the errors in verbal medication orders (i.e., orders that are transmitted orally). The Council comprises 20 national health care organizations representative of the health professions, government, and consumer and patient safety organizations. The Council’s recommendations focus on verbal orders that are communicated orally between senders and receivers, such as via a telephone call. Orders are frequently given verbally in emergency situations, where immediate written or electronic communication is not feasible, and as call-in prescriptions to community pharmacies. The Council’s recommendations are designed to be incorporated into the standard operating procedures of health care organizations, including community pharmacies, physicians’ offices, hospitals, nursing homes, and home care agencies. The Council’s recommendations include a call for limiting the use of verbal medication orders to urgent situations where immediate written or electronic methods are not feasible. The Council recommends health care systems and organizations establish policies and procedures that would help eliminate errors that occur as a result of a miscommunication, such as repeating the order back to the prescriber and immediately reducing the order to writing. The Council suggests the proper dictation of spoken numbers, such as "fifty milligrams…five-zero milligrams" to distinguish from "fifteen milligrams…one-five milligrams." The Council also suggests that verbal orders for antineoplastic (anticancer) agents should not be permitted under any circumstances because of their narrow margin of safety. "We view these recommendations as another step toward continued improvements in the systems approach to reducing medication errors," said Council Chairperson Jerry Phillips, associate director for medication error prevention, Office of Post-Marketing Drug Risk Assessment, Food and Drug Administration. "Errors resulting from verbal orders have always been an area of concern and frustration for the Council, Mr. Phillips continued. "We encourage all health care practitioners and organizations to incorporate these recommendations as part of their standard operating procedures so that medication errors can be reduced." The Council developed these recommendations to address the importance of recognizing the potential for errors in the use of verbal orders and to reduce medication errors pertaining to verbal orders. This is the eighth in a series of recommendations by the Council. Previous recommendations have included "Reducing Errors Related to Administration of Drugs," "Avoiding Error-Prone Aspects of Dispensing Medications," and "Reducing Errors Related to Labeling/Packaging." Click here for current and previous recommendations. The United States Pharmacopeia (USP) formed the Council in 1995 to address the interdisciplinary causes of errors and to promote the safe use of medications. The Council’s mission is to reduce errors in the health care system by encouraging the reporting, understanding, and prevention of medication errors. The Council comprises 20 organizational members and one individual member. The Council includes:   American Association of Retired Persons Generic Pharmaceutical Association American Health Care Association Healthcare Distribution Management Association American Hospital Association Institute for Safe Medication Practices American Medical Association Joint Commission on Accreditation of Healthcare Organizations American Nurses Association National Association of Boards of Pharmacy American Pharmaceutical Association National Council of State Boards of Nursing American Society for Healthcare Risk Management National Patient Safety Foundation American Society of Consultant Pharmacists Pharmaceutical Research and Manufacturers of America American Society of Health-System Pharmacists U.S. Pharmacopeia Department of Veterans Affairs Deborah Nadzam, Ph.D. (individual member) Food and Drug Administration William Kelly, Pharm. D. (ex officio)   For additional information about the Council, its activities or membership, contact Council chairperson Jerry Phillips (301-827-3246), or Council secretary Diane D. Cousins (301/816-8215). # # # # The National Coordinating Council for Medication Error Reporting and Prevention (Council) was founded in 1995 to promote the reporting, understanding and prevention of medication errors. The Council comprises health-related organizations, societies and agencies, including medicine, pharmacy and nursing groups, consumer groups, standards-setting and federal regulatory bodies, and manufacturers. The Council’s goals are to examine and evaluate the causes of medication errors; increase awareness of medication errors and methods of prevention throughout the health care system; recommend strategies relative to system modifications, practice standards and guidelines; stimulate development and use of medication error reporting and evaluation systems; and stimulate reporting to a national system for review, analysis and development of recommendations to reduce and prevent medication errors. 2001-01 NCC MERP Attachment: Recommendations to Reduce Medication Errors Associated with Verbal Medication Orders and Prescriptions © 1998–2008 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. *Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.