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.