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Postgrad Med J. 2009 Sep;85(1007):460-3. doi: 10.1136/qshc.2009.034041.

Are verbal orders a threat to patient safety?

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  • 1University of Missouri Center for Health Care Quality (CHCQ), One Hospital Drive, Columbia, MO 65212, USA.



The use of verbal orders has been identified as a potential contributor to poor quality and less safe care. As a result, many organisations have encouraged changing the verbal orders process and/or reducing/eliminating verbal orders altogether (Joint Commission (2005), Institute of Medicine (2001), Leapfrog organisation, Institute of Safe Medication Practices). Ironically there is a paucity of research evidence to support the widespread concern over verbal order.


This paper describes the very limited existing research on verbal orders, presents a model of verbal order use identifying potential error trigger points and suggests a verbal order research agenda in order to better understand the nature and extent of the potential patient care safety threat posed by verbal orders.

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