Verbal Prescriptions: Best Practices for Clarity and Safety in Healthcare

Every year, thousands of patients in U.S. hospitals are at risk not because of a bad drug, but because of a misheard word. A nurse hears hydralazine but the doctor said hydroxyzine. A dose of fifteen milligrams becomes fifty because the prescriber didn’t say one-five. These aren’t hypotheticals-they’re real events that have led to overdoses, ICU transfers, and even deaths. Verbal prescriptions are still common in healthcare, even in 2025. And if they’re going to be used, they need to be done right.

Why Verbal Prescriptions Still Exist

You might think electronic prescribing made verbal orders obsolete. But that’s not true. In emergency rooms, operating rooms, and during patient transfers, there’s no time to log into a computer. A trauma patient needs epinephrine now. A surgeon in the middle of an operation can’t step out to type a prescription. Verbal orders fill that gap. According to the Agency for Healthcare Research and Quality, hospitals still use verbal prescriptions in 10-15% of cases. In high-pressure areas like the ER, that number jumps to 25-30%.

The problem isn’t that verbal orders exist. It’s that they’re often done poorly. Studies show that without strict protocols, error rates can hit 30-50%. The Institute for Safe Medication Practices Canada calls verbal orders “known to be susceptible to error.” But here’s the key: when done correctly, they’re not the enemy. They’re a necessary tool-and like any tool, they need the right technique.

The One Rule That Saves Lives: Read-Back Verification

There’s one practice that separates safe verbal prescriptions from dangerous ones: read-back verification. It’s simple. The person receiving the order repeats it back word-for-word to the prescriber. The prescriber confirms it’s correct. That’s it.

The Joint Commission made this mandatory in 2006. It’s not optional. And it’s not just a formality. A 2006 study from the Agency for Healthcare Research and Quality showed that when read-back is used properly, medication errors drop by up to 50%. In one NICU case, a premature infant was almost given a lethal dose of antibiotics because two drugs were ordered at once. The nurse didn’t read back the order. The error was caught only because a second nurse questioned it.

But here’s the catch: read-back doesn’t happen nearly enough. A 2020 survey of nurses found that 63% reported prescribers resist read-back. Some think it’s slow. Others think it’s unnecessary. But when a nurse says, “I heard you say 50 mg of hydralazine,” and the doctor replies, “No, I said 5 mg-hydroxyzine,” that’s a life saved.

How to Say It Right: Phonetics, Numbers, and No Abbreviations

It’s not enough to just repeat the order. You have to say it clearly. The Institute for Safe Medication Practices gives exact rules:

• Spell out drug names phonetically. Don’t say “Zyprexa.” Say, “Z-Y-P-R-E-X-A.” Confusion between Zyprexa and Zyrtec has caused fatal allergic reactions.
• Use two methods for numbers. Say “fifteen milligrams” AND “one-five milligrams.” This stops confusion between 15 and 50.
• Avoid all abbreviations. Never use “BID,” “QID,” or “PO.” Say “twice daily,” “four times daily,” or “by mouth.”
• Clarify units. Always say “milligrams,” not “mg.” Say “milliliters,” not “mL.”

Sound like overkill? It’s not. A 2021 Medscape survey of 1,200 nurses found 68% had a near-miss every month because of unclear speech. One nurse in San Diego recounted how a doctor said “Hydralazine” like “Hydroxyzine.” The nurse asked for spelling. “H-Y-D-R-A-L-A-Z-I-N-E,” the doctor said. The nurse caught the error. That’s the difference between a routine shift and a patient code.

High-Alert Medications: When Verbal Orders Are Forbidden

Some drugs are too dangerous to order verbally-unless it’s an emergency. The Pennsylvania Patient Safety Authority and Washington State Department of Health both list these as high-alert:

• Insulin
• Heparin
• Opioids (morphine, fentanyl, hydromorphone)
• Chemotherapy agents
• Concentrated electrolytes (potassium chloride, sodium chloride)

In most hospitals, verbal orders for these are banned unless the patient is actively crashing. Even then, the order must be read back, documented immediately, and authenticated within the same shift. Johns Hopkins Hospital’s policy says no verbal order for insulin unless the patient is in DKA and the prescriber is physically present. That’s not bureaucracy-it’s biology. One wrong decimal point can kill.

What Must Be Documented-And When

A verbal order isn’t real until it’s written down. And not just written-it’s written with full details:

• Patient’s full name and date of birth
• Medication name (spelled out)
• Dose with units (e.g., “5 milligrams”)
• Route (e.g., “intravenous,” not “IV”)
• Frequency (e.g., “every 6 hours”)
• Indication (e.g., “for sepsis”)
• Name and credentials of prescriber
• Exact time and date the order was received
• Time and date of authentication

CMS requires authentication within 48 hours. But top hospitals like Mayo Clinic and UCSF require it within the same shift. Why? Because if a nurse administers the drug and the doctor forgets to sign off, who’s liable? The nurse. The system. The hospital. That’s why immediate documentation isn’t just policy-it’s protection.

Who Can Take Verbal Orders?

Not everyone can. Only licensed providers or trained staff under direct supervision can receive verbal orders. In most hospitals, that means RNs, LPNs, pharmacists, or certified medical assistants with specific training. Unlicensed staff-like receptionists or transporters-can’t take them. Ever.

CMS allows authorized documentation assistants to enter verbal orders into the EHR, but only if a licensed provider is giving the order and confirms it. That’s a big change from 2010. But it’s still not a loophole. The provider remains legally responsible.

Common Mistakes and Real Cases

Here are the top three mistakes that lead to harm:

1. Mixing multiple orders at once. In 2006, a premature infant got ampicillin and gentamicin mixed up during a transfer. Two drugs, one verbal order. No read-back. The baby suffered kidney damage.
2. Ordering during distractions. A doctor gives a prescription while checking a text message. The nurse hears “Lisinopril” but the doctor meant “Lithium.” The patient developed lithium toxicity.
3. Assuming familiarity. “You know what I mean.” That phrase has killed. A nurse in Arizona assumed “Cipro” meant 500 mg. The doctor meant 250 mg. The patient developed a resistant infection.

The common thread? No verification. No clarity. No pause.

What You Can Do-Even If You’re Not the Doctor

You don’t have to be the prescriber to prevent an error. If you’re a nurse, pharmacist, or even a patient advocate:

• Always ask for spelling-even if you’ve heard the drug a hundred times.
• Never assume. If something sounds off, say so.
• Document the time the order was received, not when you entered it.
• Report near-misses. They’re not failures-they’re warnings.
• Use the “I need to repeat this back” script: “Dr. Smith, I heard you order hydralazine 5 mg IV for hypertension. Is that correct?”

One nurse in Texas told a story about a prescriber who always rushed. She started saying, “Before I hang up, I need to read this back to make sure I got it right.” At first, he rolled his eyes. After three months, he started saying it first: “Let me say it again so you can read it back.” That’s culture change.

The Future: Less Verbal, But Never None

Voice-to-text systems are getting better. AI-assisted EHRs are reducing manual entry. KLAS Research predicts verbal orders will drop to 5-8% by 2025. But Dr. Robert Wachter of NEJM Catalyst says it right: “Some clinical scenarios will always require verbal communication.”

That’s why safety protocols aren’t going away. They’re evolving. The FDA is working on standardizing how high-risk drug names are pronounced. Hospitals are training staff on sound-alike pairs like “Celebrex” and “Celexa,” “Zyprexa” and “Zyrtec.”

The goal isn’t to eliminate verbal orders. It’s to make them safe. Because when done right, they save lives. When done wrong, they end them.