1. Cohen, Michael R. ScD, MS, RPH

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Prescribers: Put it in writing

The Institute for Safe Medication Practices (ISMP) conducted a survey to gain insight into the use of verbal orders in today's healthcare environment. The potential for verbal orders to be misunderstood, misheard, or transcribed incorrectly make them error-prone given the different accents, dialects, and drug name pronunciations used by both prescribers and recipients of the order. Add in factors such as sound-alike drug names, background noise, and interruptions, and it's not surprising that errors with verbal orders continue to be reported.


Of 1,622 survey respondents, 75% were nurses, followed by pharmacists (23%) and other practitioners. More than a quarter of respondents reported that they receive at least one in four orders verbally. Fourteen percent were aware of an error that had occurred in the past year due to mishearing, misunderstanding, or incorrectly transcribing verbal orders. Here are a few examples:


* A prescriber verbally ordered 0.2 mg of oral morphine solution for a newborn with withdrawal symptoms. The nurse transcribed the order as 0.2 mg/kg. The pharmacy clarified the dose with the prescriber and it was corrected.


* A telephone order for propafenone, a Class 1C antiarrhythmic drug, was mistaken as propranolol, a beta-adrenergic receptor antagonist.


* "50" mg was misheard as "15" mg.


* During an emergency at the bedside, a prescriber asked for "10" of diazePAM. A nurse prepared 10 mL (5 mg/mL), not the intended 10 mg.


* Subcutaneous EPINEPHrine was prescribed verbally. The route was misunderstood and the drug was administered I.V.


* A physician verbally ordered "100 mg of Toradol" (ketorolac, a nonsteroidal anti-inflammatory drug), when he meant to say "traMAdol" (a centrally acting analgesic).



To prevent errors and near-misses such as these, verbal orders should be limited to true emergencies or situations in which the prescriber is physically unable to electronically transmit or fax an order (for example, when a prescriber is working in a sterile field). Healthcare facilities should have policies and procedures specifying when verbal orders are acceptable, defining the prohibitions and limitations on verbal orders, and establishing requirements for clear communication of verbal orders, including a read-back process. For a full discussion, visit



Don't put the squeeze on round bottles

Several patients reported to their local pharmacy that they'd run out of their topical ophthalmic solutions early-so early, in fact, that their insurance plans wouldn't pay for refills, so they were without their medication for several days. Investigation revealed that the medication had been provided in a round Drop-tainer bottle, which the patients were squeezing at the sides to produce drops. To express drops, this type of bottle should be pushed on the bottom, not squeezed on the sides; doing so expels excess medication.


As shown above, two versions of Alcon's Drop-tainer eye drop bottles are currently available for some of their ophthalmic solutions. Unlike the oval bottle, the round bottle is designed to dispense a drop when its bottom is pressed. Unfortunately, the manufacturer didn't design the round bottle to prevent the user from incorrectly squeezing its sides instead (for example, by making the bottle walls too thick to squeeze).


Many practitioners and patients are unaware of the unique administration method these bottles require. Current product labeling and prescribing information doesn't provide clear instruction for proper use, although patient information leaflets describing their proper use are available from the manufacturer.

Figure. To dispense ... - Click to enlarge in new windowFigure. To dispense one drop of medication, patients should push the bottom of the round Drop-tainer bottle (left). Squeezing the sides instead expels too much medication. To dispense a drop from an oval Drop-tainer bottle, however, they should gently squeeze the bottle's sides (right).

Companies whose products are packaged in these containers should provide clear instructions for proper use as part of product labeling, and clinicians should be made aware of the differences in these containers so they can educate patients about proper administration technique. The patient information leaflets from the manufacturer describing how to use oval and round Drop-tainer bottles should be provided to patients with their prescription. Instructions for use can be found at and


The Institute for Safe Medication Practices also recommends that hospital pharmacists add a comment on the medication administration record so nurses are alerted to proper administration technique.