Verbal Prescriptions: Best Practices for Clarity and Safety in Healthcare

When a doctor calls in a medication order over the phone, it’s not just a quick chat-it’s a high-stakes moment. A single misheard word can mean the difference between healing and harm. Verbal prescriptions, while necessary in emergencies or during surgery, carry a risk that’s been well-documented for over two decades. The Institute for Safe Medication Practices Canada reports error rates between 30% and 50% when these orders aren’t handled with strict protocols. That’s not a small number. It’s a real threat to patient safety. But here’s the good news: with the right steps, those risks can be cut in half-or more.

Why Verbal Prescriptions Still Exist

You might wonder why we still use verbal orders when electronic systems exist. The answer is simple: sometimes, there’s no time. During a cardiac arrest, while a surgeon is scrubbed in, or when the EHR is down, writing an order isn’t an option. Verbal prescriptions fill that gap. They’re not outdated-they’re essential. But that necessity doesn’t excuse sloppy communication. The Joint Commission made this clear back in 2006: if you’re giving a verbal order, you must follow the rules. And those rules aren’t suggestions. They’re lifelines.

The Read-Back Rule: Your First Line of Defense

The single most effective safety step in verbal prescribing is read-back. This isn’t just repeating the order-it’s saying it back word for word, number for number, so the prescriber can confirm it’s correct. The Joint Commission required this practice in 2006, and since then, hospitals that enforce it see up to 50% fewer medication errors. But here’s the catch: read-back only works if it’s done every time, by everyone. A 2020 survey of nurses found that some prescribers skip it almost half the time. That’s not an oversight. It’s a pattern. And it’s dangerous.

Here’s how to do it right:

1. The prescriber gives the full order: medication name, dose, route, frequency, and reason.
2. The receiver repeats it back exactly as heard.
3. The prescriber confirms: “Yes, that’s correct.”
4. The order is documented immediately-no waiting.

Don’t assume the other person heard you. Don’t assume they remember. Say it. Repeat it. Confirm it. Always.

Spell It Out: No Abbreviations, No Guessing

Abbreviations are the enemy of clarity. “BID” sounds like “bid” as in “I bid you farewell.” But in a hospital, it means twice daily. And that’s not safe. The same goes for “QD” (once daily), “U” for units, or “MS” for morphine sulfate. These shortcuts have caused deadly mix-ups. The Institute for Safe Medication Practices (ISMP) says sound-alike names like Celebrex and Celexa, or Hydralazine and Hydroxyzine, are behind nearly a third of all verbal order errors.

So how do you avoid this? Spell everything out.

• Use twice daily, not BID.
• Use by mouth, not PO.
• Spell the drug name: “A-M-P-I-C-I-L-L-I-N,” not just “ampicillin.”
• State numbers two ways: “Fifteen milligrams-fifteen, one-five.”

This isn’t extra work. It’s insurance. One nurse in Auckland told me she once caught a 10-fold dosing error because the prescriber said “hydralazine” without spelling it. She asked for clarification. The prescriber corrected himself: “I meant hydralazine-H-Y-D-R-A-L-A-Z-I-N-E.” That pause saved a life.

High-Alert Drugs: When Verbal Orders Are Forbidden

Not all medications should be ordered verbally. Some are too dangerous. The Pennsylvania Patient Safety Authority and Washington State Department of Health agree: insulin, heparin, opioids, and chemotherapy should never be ordered verbally unless it’s a true emergency. Even then, extra caution is required.

Here’s what’s off-limits for verbal orders in most hospitals:

• Insulin (especially sliding scale or IV)
• Heparin (unfractionated or low molecular weight)
• Opioids (fentanyl, morphine, hydromorphone)
• Chemotherapy agents (except to hold or discontinue)

Why? Because a small mistake here leads to a big disaster. A premature infant in a 2006 NICU incident received ampicillin and gentamicin at 10 times the correct dose because two drugs were ordered back-to-back without clear separation. The nurse didn’t catch it. The prescriber didn’t spell them out. The baby nearly died.

If you’re unsure whether a drug is high-alert, check your hospital’s list. If it’s not on the list, ask. Better to pause than to poison.

Documentation: The Only Real Record

Here’s the hard truth: the only record of a verbal order is in the memories of the people who heard it. That’s why immediate transcription isn’t optional-it’s mandatory. CMS requires authentication within 48 hours. But leading hospitals like Johns Hopkins require it before the shift ends. Why? Because memory fades. Distractions happen. A nurse might be called away to a code blue. A doctor might get interrupted by a family member. By the time they get back, they’ve forgotten half the order.

Every verbal order must include:

• Patient’s full name and date of birth
• Medication name spelled phonetically
• Dose with units (mg, mL, units-not just “10”)
• Route (IV, IM, PO, SC)
• Frequency (twice daily, every 6 hours)
• Indication (why it’s being given)
• Prescriber’s full name and title
• Time and date the order was given
• Time and date the order was authenticated

Missing any one of these? That’s not a paperwork issue. That’s a safety gap.

Who’s at Risk? The Hidden Danger Zones

Most verbal order errors happen during shift changes. That’s when fatigue, distractions, and rushed handoffs collide. The Pennsylvania Patient Safety Authority found 42% of errors occur during these transitions. Nurses report that some prescribers never use read-back. Others speak too fast. Some use unclear accents or mumble. A 2021 Medscape survey showed 68% of nurses had at least one near-miss every month because of unclear speech.

Non-native English speakers are especially vulnerable-not because they’re less competent, but because communication systems weren’t built for them. A doctor saying “fifteen milligrams” might sound like “fifty” to someone unfamiliar with the accent. That’s why stating numbers two ways (“fifteen-fifteen, one-five”) is so critical. It’s not about politics. It’s about precision.

And don’t forget: the person receiving the order has as much responsibility as the one giving it. If something sounds off, ask. If you’re unsure, say: “Can you repeat that?” No one will think less of you. In fact, they’ll respect you more.

What’s Changing? The Future of Verbal Orders

Electronic prescribing has cut verbal order rates from 22% to under 10% in hospitals since CPOE systems were adopted. KLAS Research predicts that by 2025, verbal orders will drop to just 5-8%. Voice recognition software and AI-assisted order entry are making it easier than ever to skip the phone call.

But here’s the reality: some situations will always need verbal orders. Surgeons in the OR. Paramedics in the field. A code blue in the middle of the night. That’s why safety protocols aren’t going away. They’re evolving. In 2024, the FDA is launching a national initiative to standardize how high-risk drug names are pronounced. That means “Hydralazine” will have one official way to say it-no more guessing.

And more states are making read-back mandatory. By 2023, 42 states had adopted The Joint Commission’s standards into their licensing rules. That’s not just policy. It’s law.

Final Rule: When in Doubt, Stop and Confirm

There’s no shortcut to safety. No clever trick. No app that replaces common sense. The best practice is simple: slow down. Spell it. Read it back. Write it down. Double-check. If you’re tired, distracted, or rushed, say so. Ask for help. Ask for clarification. You’re not being difficult-you’re being responsible.

One nurse summed it up perfectly: “I’d rather be called slow than be the one who gave the wrong drug.”