Compliance with verbal orders standards poor
Among the most challenging standards from The Joint Commission for the first half of 2008 was standard IM.6.50 — "Designated qualified staff accept and transcribe verbal or telephone orders." According to the organization, 40% of hospitals were not in full compliance. (This standard is now in a new chapter, under "RC" as opposed to "IM.".)
This problem is not surprising to ED managers, who say the hectic pace in their departments can make compliance with this standard quite challenging. "In an emergency setting, you do not take care of one patient at a time; it's not a linear process," notes India Owens, MSN, CEN, director of emergency services at Clarian West Medical Center in Indianapolis. "It's a different world than, say, the inpatient world."Â
Owens offers this hypothetical situation: A patient is vomiting, and the doctor has ordered medication in written format. The nurse goes in to recheck the patient and sees he has continued to vomit. She seeks out the doctor, who is heading to another room where a second patient is having a heart attack. The nurse tells the physician the patient is still vomiting, and he says the dosage should be increased. "This is all done on the go," she says. "The nurse writes down or asks the doctor to write down the order when they get the chance."
This is not to say the "transcription" part of the standard is impossible to meet. Owens says she has devised solutions for paper-based and electronic systems. (Her department switched to computerized physician order entry [CPOE] about nine months ago.)
"Prior to the switch, we solved the problem somewhat by having a single sheet that was used by both doctors and nurses," she says. "On one side at the top was the physician order, and at the bottom was the nurse's sign-off."
With this system, she explains, if the nurse wrote the verbal order down, the doctor still had access to that same piece of paper to sign it, and vice versa. "In many places there are two different sheets of paper," notes Owens. "Here, the nurse could just hand the doctor the chart and say, 'Write it on the clipboard.'"
Now that the department has switched to CPOE, "you would not have this problem as consistently with verbal orders because the system 'forces' the doctor to write," Owens says. As soon as a nurse enters a verbal order, she explains, it flows to the physician's inbox for him or her to sign. "If you set your system up well, it closes the gap on this problem," Owens says.
A solid policy will address the issue of having only qualified personnel transcribe the orders, adds Kathy Hendershot, RN, ED clinical director at Methodist Hospital in Indianapolis. "We have a policy that verbal orders cannot be taken by anybody except a registered nurse employed by the hospital," she says.
Documentation also can be a problem, Hendershot says. "It clearly starts with the policies and procedures within your organization meeting the standard; then, you 'teach to the test,'" she says. Once the policy was written and rolled out, Hendershot says, it was "cascaded" through organization management. "It's important to make sure the medical staff understands it," she adds.
Because the hospital still is on a paper system, "unless it is an emergent situation — usually resuscitation — we tell nurses they can't take a verbal order," Hendershot says. "They know now that in case they need an order, they will carry a form with them and ask the physician to write it down."
In cases where verbal orders are used, the nurse is required to call back the order to the physician. "Usually, we document the order on the chart as a read-back a verbal order, or RBVO, and the physician has to sign off on that," she explains.
To help ensure compliance, Hendershot conducts a significant amount of education. "Within our department we've done inservices, unit meetings, posters, mass e-mails, and we've made it part of our National Patient Safety Goal education," she says.
Among the most challenging standards from The Joint Commission for the first half of 2008 was standard IM.6.50 â "Designated qualified staff accept and transcribe verbal or telephone orders." According to the organization, 40% of hospitals were not in full compliance. (This standard is now in a new chapter, under "RC" as opposed to "IM.".)You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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