Patients are at greater risk of medication errors when clinicians order drugs in person or via telephone, according to the Pennsylvania Patient Safety Advisory, an independent state agency. It recommends a read-back procedure in which the person receiving the order writes it down, reads it back, and gets confirmation that the prescription was understood correctly.


Reports submitted to the confidential Web-based Pennsylvania Patient Safety Reporting System include many errors that could have been prevented if the read-back system was used. Most medication errors (99%) submitted to the system do not result in patient harm. However, the risk of harm remains a concern since such errors make up the largest num-ber of reports submitted to the system overall—26%. According to statistics, medication errors are also a major problem throughout the country.

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Accents, dialect, background noise, interruptions, and unfamiliar drug names all contribute to misinterpreting verbal prescriptions. While limiting verbal orders as much as possible is the surest way to avoid errors, the agency also recommends these steps:

  • Limit verbal prescription or medication orders to urgent situations in which immediate written or electronic communication is not feasible.
  • Enunciate clearly.
  • For all medication orders, include the purpose of the drug to ensure that the order makes sense in the context of the patient’s condition.
  • Express doses by unit of weight (e.g., mg, g, mEq, mmol) rather than in terms of number of tablets, ampules, or vials.
  • Have a second person listen to an order whenever possible.
  • Record the prescription directly onto an order sheet in the patient’s chart.
  • Limit verbal orders to formulary drugs.
  • Limit the number of personnel authorized to receive telephone orders.
  • Whenever possible, have a pharmacist receive verbal orders
  • for medications.