Does this sound familiar? A physician calls with telephone orders for one of your patients. It’s one of “those” days. The nurses station is frantic with activity and noise. Other phones are ringing, people are at the desk asking questions, admissions are coming in, discharges are waiting to go home, and here you are trying to get critical information from a physician over the phone.

This was probably one of the scenarios that The Joint Commission had in mind when it addressed effective verbal/telephone communication between healthcare providers in its National Patient Safety Goals. Almost 100,000 people in the United States die each year as a result of medical errors,¹ and ineffective communication, including on the telephone, contributes significantly to these errors. In fact, The Joint Commission has described communication problems as the No. 1 cause of sentinel events, the unexpected incidents that result in death or serious, permanent injury to a patient — or the risk of such harm (a “near miss”).

The National Patient Safety Goals have included a category on communication in health care ever since their introduction, in 2003. The communication goal started out with two safety measures: the read back of verbal/telephone orders and the use of standard abbreviations. In 2005, The Joint Commission added a third item, the timely and accurate reporting of critical lab results, and in 2006, a fourth, a requirement for standardizing “handoff” communications. All these requirements continue in 2008.¹ From taking an order over the phone to handing off a patient to another department, nurses face situations involving potential communication problems every day. Nurses must understand and adopt safety practices to ensure the smooth functioning of the healthcare team — and the safety and optimal care of their patients.

What did you say?

Verbal or telephone orders are a significant source of medical errors. Errors can occur not only in the scene described above at the nurses station, but also when the person giving an order is difficult to understand. Think about all the accents, dialects, and pronunciation patterns heard in almost any hospital these days — and how orders could be misinterpreted, leading to a medical error. Other dangers of telephone or verbal communication are interruptions, distractions, unfamiliar drug names or terminology, medications with sound-alike names, and reliance on memory when writing down an order at a later time.^1,2 All are recipes for disaster.

Another consideration is the speed with which verbal or telephone orders are carried out. Actions resulting from verbal and telephone orders usually occur right away, giving little time for correction if the person taking the order noted it erroneously. With verbal or telephone orders, the person giving the order has a natural tendency to expect that the person taking the order will understand it and copy it accurately into the medical record. But even if the person taking the order understands it, he or she may make an error in transcribing it.

As part of its National Patient Safety Goals, The Joint Commission requires the person receiving a verbal or telephone order to write down the complete order or enter it into a computer as it’s being given, then read it back and receive confirmation from the person who gave the order. This ensures the accurate transcription of all verbal or telephone orders, not just the more common medication orders. The read-back process also applies to critical test results, which will be covered later. In emergencies, such as a code or during surgery in the OR, this read-back process may not be possible. In this case, a “repeat back” is acceptable.¹

The best way to prevent errors resulting from verbal or telephone orders is to limit their use.² But this is easier said than done. It’s much easier for the provider to give a verbal or telephone order than to write it in the medical record. The Joint Commission suggests that organizations make the written process as easy as possible. Organizations have done this in various ways, including using preprinted order sheets with check boxes or having providers fax written orders if they aren’t onsite. Organizations fortunate enough to have computerized physician order entry may use handheld computers or easy-access terminals to make it convenient for providers to electronically enter their orders.²

The Joint Commission makes these additional suggestions to improve the verbal/telephone order process and ensure safety:¹

• Ask the provider for the correct spelling of a medication if you are unsure.
• When repeating an order back to the provider, spell out numbers, e.g., 17 would be one — seven.
• Avoid using abbreviations. For example, “1 tab t.i.d.” should be stated as “Give one tablet three times daily.”
• Have a second person listen to the verbal/telephone order whenever possible, especially if an inexperienced nurse is taking the order.
• Record a verbal order directly onto the physician order sheet. This eliminates transcription as a source of error.
• Limit the number of people who are allowed to receive verbal orders and be sure they are familiar with the verbal/telephone order policy.
• Restrict the use of verbal/telephone orders in certain areas, e.g., oncology, where chemotherapeutic drugs are involved. Any drugs that are high risk and have complicated or sound-alike names should not be prescribed verbally.
• Write the purpose of the drug on the order. The order should also include the drug name, dosage form, strength of concentration, frequency, route, quantity, and duration.

Employees should take verbal/telephone orders for only things that are within their scope of practice, e.g., a ward clerk should not take a practitioner’s verbal order for patient-related issues.

Read back does make a difference. One study examined what happened when residents entered verbal orders from attending physicians into bedside computer terminals during rounds.³ At first, the study found that 9.1% of the entries were in error, mostly in drug dosages. In the second part of the study, before leaving a patient’s room the residents read back the order that they had entered into the computer. The attending physician or chief resident then verified its accuracy. With the read back added, the error rate fell to zero.³

Devilish details

Another source of medication errors is dose designations that include decimal points. For example: A patient gets 10 times the normal dose of a medication because the nurse did not see the decimal point in the “1.0” written by the physician, or an order for “.1 mg” is interpreted as “1 mg” because the nurse doesn’t see the decimal point.

Overdoses can also easily result from using a trailing zero when none is needed, e.g., 1.0 mg instead of 1 mg, or failing to use a leading zero when writing a fractionated dose, e.g., .1 mg instead of 0.1 mg. All these are real-life errors that could happen at any time.

The Joint Commission’s National Patient Safety Goals require facilities to have a standardized list of “do-not-use” abbreviations to include the following dose designations, abbreviations, acronyms, and symbols:

• The abbreviations “U” and “IU,” which can easily be mistaken for the number “0,” especially when the “U” is written too closely to the number. For example, a patient could receive 60 units of insulin because the nurse interprets “6U” as “60.” Or, “IU” could be misinterpreted as “IV” or the number “10.” The safest way is to write out “unit” and “international unit.”
• The abbreviation “q.d.” (every day), which can be read as “q.i.d.” (four times a day), especially if the period after the “q” or the tail of the “q” is misunderstood. Writing out “every day” will eliminate this error. Similarly, the abbreviation “q.o.d.” (every other day) can be seen as “q.d.” or “q.i.d.” if the “o” is poorly written. The correct form here is to write out “every other day.”
• The last of The Joint Commission mandates on abbreviations relates to magnesium sulfate (MgSO4) and morphine sulfate (MSO4). When MgSO4 and MSO4 are written hastily, they can easily be confused. Write out magnesium sulfate and morphine sulfate so there can be no mistake which is intended.⁴

Old habits

The Joint Commission recommendations on abbreviations have been difficult to enforce, largely because of ingrained behavior. Changing the order practices of physicians who have been writing orders the same way for 10, 20, or 30 years is challenging. The same can be said of nurses who take physicians’ orders verbally or telephonically and use nonstandard abbreviations on the order sheet or when transcribing orders to the medication administration record. The Joint Commission asked accredited hospitals how they handle the dangerous abbreviation issue. Below are several suggestions:⁵

• Print an authorized abbreviation list at the top or bottom of order sheets or in the margins.
• Provide physicians and staff with pocket-size, laminated abbreviations cards with a hole on top so they can be hung with ID cards.
• Print an abbreviation list and laminate it to the physician orders section chart divider.
• Review all preprinted order forms and modify as necessary.
• Educate, monitor, and provide feedback to physicians and staff who document in the medical record.
• Make dangerous abbreviations (and all National Patient Safety Goals) an agenda item at all medical staff department/section meetings.
• Run articles in physician and employee newsletters about “do-not-use” abbreviations.

Another approach is having the pharmacy refuse orders that contain prohibited abbreviations. The order must be corrected with the proper abbreviation before the pharmacy processes it. Nurses can play a part by notifying the prescribing physician before the order is sent to the pharmacy. But some physicians have become so upset with “prohibited abbreviation” calls that they have refused to change orders or answer the phone or their pager. The upshot is a delay in the patient’s medication.⁶

The bottom line is to focus on the elimination of prohibited, error-prone abbreviations as a systemwide concern, not one just for nurses, pharmacy, or physicians. To create a culture of safety regarding abbreviations, hospital and medical staff leadership needs to promote educational efforts, physician “champions” must support the initiative, and clinicians must encourage their peers to adhere to the program. This must be a “physician-owned” process to enforce physician compliance.⁶

Situation critical

If you’ve ever watched a movie or a TV show depicting conversations between a pilot and control tower, you have noticed that when pilots receive instructions, they repeat back to the tower what they heard. The airline industry dealt with accuracy of verbal instructions many years ago when it determined that many “near misses” were due to pilots’ misinterpretation of instructions from ground controllers. The healthcare sector now is learning from the airlines. Inaccurate interpretation of critical test results is analogous to the misinterpretation of a ground controller’s instructions: Both can lead to injury and even death.

A lack of timeliness in reporting the results of critical tests can be equally devastating. Studies have shown significant delays often occur in reporting test results that are dangerously abnormal. Prompt treatment for severely elevated or lowered sodium, potassium, or glucose is critical to the patient’s survival.⁷

To highlight this patient safety issue, The Joint Commission developed two requirements under the communications goal, one related to reading back telephonic reports of critical test results and one related to the timeliness of reporting critical test results to the responsible licensed caregiver. The same rules that apply to reading back verbal and telephone orders apply to reading back reports of critical test results; this section will focus on timeliness.

To have hospitals to focus on timeliness, The Joint Commission requires them to “measure and assess” the timeliness of reporting critical test results and, if appropriate, take action to improve the timeliness with which the responsible licensed caregiver receives critical test results. Hospitals are now required to have a system that documents the time a critical test result was phoned to and received by a licensed provider. If the test result was phoned to a nursing unit and the nursing unit then notified the provider, the time between those two actions is also recorded. Clinical administrators then must assess the data and determine whether the times of notification are appropriate and if not, develop a plan to improve them. The Joint Commission does not prescribe a time frame for reporting; it is up to the organization to determine an acceptable time to get critical test results to a provider who can take action on the results.⁷

The objective of the requirement is to avoid unnecessary delays in treatment. Reporting to an intermediary, such as a physicians office or a unit nurse, will add more time to the process; however, analysis of the data will reveal whether reporting to an intermediary is a true delay or whether it is actually a more expeditious way to get the information to the caregiver.

To comply with the requirement on reporting critical test results, the organization first must define what constitutes a critical test result, which may come from the laboratory, cardiology, or radiology departments or the inpatient, emergency, or ambulatory settings.⁹ If an organization fails to define critical test results, Joint Commission surveyors will consider all verbal and telephone reports of diagnostic tests to be “critical.”⁸ A common definition of a critical test result is any value or interpretation for which a delay in reporting can result in serious adverse outcomes for patients. For “critical results” that involve an interpretive component, developing a list of common findings that warrant rapid communication (i.e., “panic values”) may prove useful. Some tests, often known as STAT tests, require rapid communication even if the results are normal.⁹

Once an organization has defined critical test results, it must address the measurement aspect of The Joint Commission’s recommendation. The organization needs to establish what it expects the reporting time to a licensed provider will be. For STAT tests, the reporting time would measure the time from when the test was ordered to when the result was reported to the licensed provider.

For panic values, the reporting time would be from the time the value was identified to the time it was reported to the licensed provider.

When developing a critical test result reporting policy, organizations may want to refer to guidelines from the Massachusetts Coalition for the Prevention of Medical Errors:¹⁰

• Identify to whom the results should go. (That person must be able to take action.)
• Identify to whom the results should go if the ordering provider is not available.
• Define what test results require timely and reliable communication.
• Define the expected time frame for reporting test results to the ordering provider.
• Identify how the responsible provider should be notified (direct contact, through an intermediary).
• Ensure that the policy incorporates all types of test results (from radiology, cardiology, pathology, etc.).
• Design reliability into the system. (Require providers to include their pager numbers when ordering tests, especially critical or STAT tests.)
• Educate staff and providers to ensure broad knowledge of the critical test result communication policy

Your turn

Half of the communication breakdowns in health care occur when one caregiver hands off patient care responsibilities to another.¹¹ Consider this scenario: A patient hospitalized with a thoracic spine injury has to have a routine chest X-ray. The nurse tells the transporter about the patient’s injury and says the patient needs to remain flat and not be logrolled when transferred between beds. When the transporter delivers the patient to radiology, he puts the patient in the holding area because the department is running late. The transporter leaves. When it comes time for the X-ray, the patient is placed in an upright position to maximize the quality of the study. After the X-ray is completed, the patient returns to her room. When the patient’s nurse sees the woman, she is still sitting upright. The nurse lowers the head of the bed and notifies the physician. A neurologic exam reveals that the patient cannot move her legs.¹²

Given the tremendous number of times handoff communication takes place and the opportunities for miscommunication, it’s easy to see why The Joint Commission addressed the issue in its safety goals. It requires that hospitals “implement a standardized approach to handoff communications, including an opportunity to ask and respond to questions.” When handing off a patient, caregivers must provide information to staff members receiving the patient that reflects the patient’s current condition, treatment, recent changes in condition, and possible changes or complications to observe for. This must be done in a consistent manner throughout the organization. But the process may be modified based upon the type of handoff, e.g., nursing shift-to-shift report, a patient transfer from the ER, or a patient going to a radiology exam.

Speaking SBAR

One way to provide standardize information during handoff is the SBAR technique, which stands for “situation, background, assessment, and recommendation.” SBAR helps the communicator organize his or her thoughts and increases the chances the person listening will understand. Brief definitions for SBAR follow:

• Situation — Communicate what is occurring and why the patient is being handed off to another department or unit.
• Background — Explain what led up to the current situation and put in context if necessary.
• Assessment — Give your impression of the problem.
• Recommendation — Explain what you would do to correct the problem.

Putting SBAR into a nursing context — for example, transferring a patient to an ICU from an acute care unit — communication might go like this: “This is Mr. B. He is being transferred because he has been having trouble breathing, and his oxygen saturation continues to decrease (situation). He was admitted two days ago with COPD and has a history of congestive heart failure and pneumonia. He is being treated with bronchodilators and oxygen (background). His most recent vital signs were BP 160/100, pulse 110, respirations 30, temp 99, oxygen saturation 89%. He is experiencing significant dyspnea. Dr. Smith ordered a transfer to ICU for closer observation and evaluation by an intensivist for possible intubation and ventilatory support (assessment). He will probably need arterial blood gases, and respiratory therapy should be alerted. His family should be notified of his transfer (recommendation).” The receiving nurse now can ask questions to clarify anything he or she didn’t understand. This example of SBAR can be modified to fit the situation, e.g., change of shift report or the transfer of a patient to another facility. The most important thing to remember is that any time a handoff occurs, the opportunity for error exists. Effective handoff communication significantly reduces the chance of errors.

The hospital can be a safe environment only through staff diligence and awareness of the safety pitfalls that pervade each patient encounter. By understanding the patient safety issues related to verbal and telephone orders, abbreviations and symbols, reporting of critical test results, and handoff communication, nurses can reduce the likelihood of medical errors and patient injuries. Patients trust that you will protect them in this potentially dangerous environment. Knowing the dangers is your first step!