Dangers of Telephone Orders

The Institute for Safe Medication's (ISMP) newsletter Nurse Advise-ERR has some interesting information and cases regarding telephone orders in the July 2008 newsletter. They give warnings about several cases where fraudulent telephone orders were given and then follow with helpful hints for nurses getting telephone orders.

My favorite is a teenager who worked at the hospital who had aspirations to be a physician began answering pages to on-call residents. As an employee, the teenager could access the paging system. His actions of issuing orders for 6 patients (lab tests, oxygen orders, heparin orders) were not caught right away because the orders were medically appropriate!!!

The ISMP points out that telephone orders are only in emergent or urgent cases and that nurses should be suspicious if anything seems unusual or if you don't recognize the caller. They then detail steps that can be taken to verify the caller's identity.

Be sure to sign up for the monthly newsletter because it has helpful hints and they give examples of medication errors that have arisen. There is one in the July issue involving a handwriting problem that could have led to a medication error. There is also a link to a web seminar titled "Physical Design and Workflow of an Organization to Support Patient Safety." This webinar will discuss how design can help patient safety.