These dreaded words.
I have asked my team to help me explain what are verbal orders.
Verbal orders can be for diagnostic tests, treatments, medication and care that we as clinicians deliver verbally to the other members of our team. We frequently provide verbal orders at the conclusion of our clinic assessment and pass these on to our nursing team for entry into the Epic system.
Who can give verbal orders? Licensed practitioners who can give verbal orders include physicians and dentists, physician Assistants (PA), advanced registered nurse practitioners (ARNP) and optometrists who have been granted clinical privileges by UIHC.
Who can receive verbal orders? This depends on if the verbal order is for medication. For medication, personnel who are approved to accept verbal orders in both inpatient and outpatient settings (and related to their scope of practice) are: registered nurses, licensed practical nurses, registered pharmacists, registered dietitians, respiratory therapists, radiology technologists, and nuclear medicine technologists.
Those who can accept a verbal order for nonmedication include: registered nurses, licensed practical nurses, medical assistants, registered pharmacists, physical/occupational/speech therapists, registered dietitians, radiology technologists, nuclear medicine technologists, respiratory therapists, psychologists, sonographers, laboratory technicians, and social workers.
And for us in the clinic setting for verbal medication orders, staff approved to accept verbal medication orders may accept a verbal order in the ambulatory setting for an order set in which the drug name, dosage, route, frequency, and indication are defined and there is no option to edit any of these discreet data fields. Additionally, no verbal medication order may be given or accepted for an initial dose of sedation. For chemotherapy, verbal orders are only acceptable in the case of a dose modification.
So why all the fuss over verbal orders? Safety. Safety. Safety. When we use verbal orders there is more room for error than orders that are written and/or then sent electronically. We all know the classic telephone game of passing on what we heard. It is not only the interpretation of what someone else says that can be inherently problematic because of different accents, dialects, and pronunciations. Background noise, interruptions, and unfamiliar terminology often can compound the transmission of verbal orders. Once received, verbal orders must be transcribed as a written order, which adds complexity and risk to the ordering process.
That said, according to our hospital bylaws, the use of verbal orders for medications should be minimized as per Bylaws Article VIII, Section 4 and be utilized in cases of emergent situations. Currently, we as the Cancer Center Clinic are outliers in the number of verbal orders each week that are given and accepted. There are a variety of reasons for this and I want to recognize our outstanding nursing and care teams who have been tremendously adaptable in our use of verbal orders. At the same time, in addition to the attention and scrutiny of the UIHC practice committee in our non-emergent use of verbal orders, I believe too by reducing verbal orders we can improve work flow efficiency of our clinic. So how can we do that without changing are practice styles?
Let me share some facts about our use of verbal orders. Last week there were a total of 6,971 verbal orders. Of these, our top 5 verbal orders given were for 1) CCC Follow-up; 2) CBC; 3) automated differential; 4) creatinine; and 5) bilirubin, total; clearly important for our workflow and honestly not so high up on the safety issues.
You might have all noticed me walking around clinic watching you practice. Right I am keeping a keen eye on how you are doing it. It is not rare that I observe a physician wait up to 10 minutes for a nurse to be free to then tell the nurse to order follow-up labs and a return visit. I have seen fellows do it and PA’s. Typically, this is a standard AVS follow-up and could have been completed by the physician in two minutes. Where’s the problem? This is an easy fix.
I have also found that when I enter my own orders, I am able to assist in the justification of the peer-to-peer requests that are often requested for diagnostic imaging. By doing my own Ct-scan ordering I provide enough rationale that prevents a peer-peer review on the back end. I am sure you all find them fun to do.
I will be doing my part helping all of you with this by providing other interesting ways of reducing our ordering, and I welcome your opinions.
- Protocols for smart sets – We can access these faster and improve efficiency.
- Nurses will pend orders for you to sign, this will help reduce verbal ordering and add a step toward the safety of the patient by letting you review the order set first.
- Please share your thoughts as well.