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Are verbal orders a threat to patient safety?
  1. D S Wakefield1,
  2. B J Wakefield2
  1. 1
    University of Missouri Center for Health Care Quality, Department of Health Management and Informatics, Columbia, Missouri, USA
  2. 2
    Harry S Truman Memorial Veterans Hospital, University of Missouri Sinclair School of Nursing, Columbia, Missouri, USA
  1. Correspondence to Dr D S Wakefield, Center for Health Care Quality (CHCQ), MA120 Medical Sciences Bld., DC375.00, One Hospital Drive, Columbia, MO 65212, USA; wakefielddo{at}


Background: The use of verbal orders has been identified as a potential contributor to poor quality and less safe care. As a result, many organisations have encouraged changing the verbal orders process and/or reducing/eliminating verbal orders altogether (Joint Commission (2005), Institute of Medicine (2001), Leapfrog organisation, Institute of Safe Medication Practices). Ironically there is a paucity of research evidence to support the widespread concern over verbal order.

Aims: This paper describes the very limited existing research on verbal orders, presents a model of verbal order use identifying potential error trigger points and suggests a verbal order research agenda in order to better understand the nature and extent of the potential patient care safety threat posed by verbal orders.

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  • Funding This work is supported by funding from AHRQ-THQIT Implementation #1 UC1HS015196 and the University of Missouri Center for Health Care Quality.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • This is a reprint of a paper that appeared in Quality and Safety in Health Care, June 2009, volume 18, pages 165–8. Reproduced with kind permission of the author and publisher.