Verbal Prescriptions: Best Practices for Clarity and Safety in Healthcare

Every year, thousands of patients are harmed not because of the medicine they were given, but because of how it was ordered. Verbal prescriptions-when a doctor says a medication order out loud instead of typing it into a computer-are still common in hospitals, ERs, and clinics. They’re fast. They’re necessary in emergencies. But they’re also one of the most dangerous steps in patient care.

Imagine this: a nurse on night shift gets a call from a busy ER physician. "Give the patient 10 mg of hydralazine IV." The nurse writes it down. The patient gets the dose. But the doctor meant hydroxyzine, a completely different drug used for anxiety, not blood pressure. The patient goes into shock. This isn’t fiction. It happened. And it’s not rare.

Sound-alike drug names like hydralazine/hydroxyzine, Celebrex/Celexa, or Zyprexa/Zyrtec cause nearly one-third of verbal order errors, according to the Institute for Safe Medication Practices. And it’s not just the names. It’s how numbers are said, how units are spoken, and whether the order is written down immediately. Without strict rules, verbal prescriptions become a game of telephone with lives at stake.

Why Verbal Prescriptions Still Exist

You might think electronic systems would have killed verbal orders by now. But they haven’t. In fact, as of 2025, 10-15% of all hospital medication orders are still given verbally. In emergency rooms, that number jumps to 25-30%. Why? Because sometimes, there’s no time.

During cardiac arrest, a surgeon in the operating room, or a trauma case where every second counts, typing into a computer isn’t an option. The patient needs medication now. Verbal orders fill that gap. But they’re not a shortcut-they’re a high-risk procedure that demands discipline.

According to the Agency for Healthcare Research and Quality, hospitals that switched to full computerized order entry (CPOE) cut verbal orders from 22% to 10% of all orders-and saw a 37% drop in medication errors. That’s powerful. But even the most advanced hospitals still need verbal orders for certain situations. The goal isn’t to eliminate them. It’s to make them safe.

The Four Rules of Safe Verbal Prescriptions

There’s no room for guesswork. If you’re giving or receiving a verbal order, you follow these four rules-every single time.

1. Read-back is mandatory. The person receiving the order must repeat it back word-for-word. Not "I think you said 5 mg," but "You ordered 5 milligrams of heparin, IV, every 8 hours, for DVT prophylaxis." If the prescriber doesn’t confirm it’s correct, don’t proceed. This single step reduces errors by up to 50%, according to The Joint Commission.
2. Spell it out. Say it twice. Never say "ampicillin." Say "A-M-P-I-C-I-L-L-I-N." Say numbers in two ways: "fifteen milligrams, one-five milligrams." Don’t say "BID" or "PO." Say "twice daily" and "by mouth." Abbreviations are a known trigger for errors. The Institute for Safe Medication Practices Canada made this rule official in 2020-and every hospital should enforce it.
3. Never give high-alert meds verbally unless it’s an emergency. Insulin, heparin, opioids, chemotherapy-these drugs can kill if given wrong. The Pennsylvania Patient Safety Authority says verbal orders for these should only happen in life-threatening situations. Even then, double-check everything. One nurse in a 2023 AllNurses thread shared how spelling out "hydralazine" prevented a 10-fold overdose. That’s the difference between life and death.
4. Document it immediately. The moment the order is given, write it down. Not later. Not when you get a free minute. Right then. Include: patient name, medication name (spelled out), exact dose with units, route, frequency, reason for the drug, who gave the order, and the exact time. The Joint Commission requires this. CMS requires authentication within 48 hours. Leading hospitals like Johns Hopkins require it before the shift ends.

What You Should Never Say (and What to Say Instead)

Some phrases are landmines. Here’s what to avoid-and what to say instead.

These aren’t suggestions. They’re safety standards. A 2021 Medscape survey of 1,200 nurses found that 68% had a near-miss error every month because a prescriber mumbled or used an abbreviation. That’s not bad luck-it’s a system failure.

Who’s at Risk-and When

Verbal order errors don’t happen randomly. They cluster in predictable places.

• Shift changes: 42% of errors happen when one team hands off to another. Fatigue, rushing, and incomplete handoffs create perfect conditions for mistakes.
• Non-native English speakers: If a doctor’s pronunciation is unclear or their accent makes similar-sounding words hard to distinguish, the risk jumps. That’s why phonetic spelling is non-negotiable.
• Multiple orders at once: A 2006 case in a NICU involved a premature infant getting the wrong antibiotics because two orders were given back-to-back. One nurse remembered one drug. The other got lost. Never give more than one order at a time.
• High-pressure environments: ERs, ICUs, and ORs have the highest rates of verbal orders. That’s why protocols there must be stricter, not looser.

And here’s the hard truth: nurses report that read-back verification happens "less than half the time" for some doctors. Why? Because they’re rushed. Because they think it’s "obvious." Because they don’t want to be "bothered." But if you skip read-back, you’re not saving time-you’re gambling with a life.

What Happens When It Goes Wrong

One case from the Pennsylvania Patient Safety Authority still haunts staff: a premature baby received 200 mg of ampicillin and 5 mg of gentamicin instead of the intended 20 mg and 0.5 mg. The error happened during a transfer. The orders were given verbally. No read-back. No documentation. The infant suffered kidney damage.

These aren’t rare outliers. They’re symptoms of a broken system. The American Nurses Association’s 2022 survey found that 79% of nurses believe verbal orders are "sometimes necessary but always risky." And 87% support mandatory read-back. The problem isn’t the people. It’s the culture.

Doctors resist read-back because they see it as a lack of trust. Nurses resist speaking up because they fear being yelled at. That’s the real danger-not the phone call. It’s the silence after it.

How to Fix It

Change doesn’t come from new rules. It comes from culture.

• Train everyone: Staff need 3-5 supervised verbal order exchanges to get comfortable with the process. Don’t assume they know it.
• Use scripts: Create a simple, standardized phrase: "I’m giving a verbal order. Please read it back to me." Make it part of the routine.
• Enforce consequences: If a doctor refuses to use read-back, document it. Report it. This isn’t about punishment-it’s about safety.
• Protect the nurse: Make it clear that asking for clarification isn’t a sign of weakness. It’s a sign of professionalism. One nurse said it best: "I’d rather look dumb than bury a patient."

Technology helps, but it doesn’t solve everything. Even with CPOE, verbal orders still happen. And they always will. The goal isn’t to eliminate them. It’s to make sure every single one is done right.

What Comes Next

The future of verbal prescriptions isn’t about eliminating them-it’s about making them foolproof. The FDA is working on standardizing how high-risk drug names are pronounced. Hospitals are rolling out voice-to-text systems that can flag unsafe terms in real time. Some are even testing AI that listens to verbal orders and alerts staff if a drug name sounds like a high-risk match.

But none of that matters if the culture doesn’t change. If a doctor still thinks read-back is "unnecessary," if a nurse still hesitates to speak up, if documentation still gets pushed to the bottom of the to-do list-then errors will keep happening.

Verbal prescriptions aren’t going away. But the way we handle them can-and must-get better. Every time you spell out a drug name. Every time you read it back. Every time you write it down before you walk away. That’s how you protect someone’s life.