Complexity of medication-related verbal orders

D. S. Wakefield
M. M. Ward
D. Groath
T. Schwichtenberg
L. Magdits
Jane M. Brokel, University of Iowa
D. Crandall


Verbal orders are a common practice in hospitals but there has been little systematic study about them. Although the potential for harm arising from the miscommunication and misunderstanding of verbal orders has been recognized, there is very little research examining their complexity. This article provides a descriptive analysis of one hospital's medication-related verbal-order events for a 1-week period. Among other things, this analysis demonstrates the presence of great variability across different patient care units related to when and the way in which verbal orders are communicated and the numbers and types of individual medication-related orders communicated within a single verbal-order event. The discussion identifies 3 categories of factors potentially contributing to the complexity of verbal orders and the potential for miscommunication, misunderstanding, and patient harm: Verbal Ordering Process and Content, Verbal Order Makers, and Verbal Order Takers.