app ksmc 070 v4 tel verbal orders

Ministry of Health King Saud Medical City

Total Quality Management Riyadh, Kingdom of Saudi Arabia

ADMINISTRATIVE POLICY AND PROCEDURE(APP)POLICY OWNER: Quality & Patient Safety Improvement Council/TQMPOLICY TITLE/DESCRIPTION: Telephone, Verbal, and Written Orders for Medication

POLICY NUMBER AND VERSION:APP-KSMC-070-(V4)

EFFECTIVE DATE: 23 Sept. 2015 REPLACES NUMBER AND VERSION: APP-KSMC-070-(V3)

REVISION DUE: 22 Sept. 2018 NUMBER OF PAGES: 9APPLIES TO: All Departments and Employees of King Saud Medical City involved in Telephone, Verbal and Written Orders for Medication.

1. STATEMENT OF PURPOSE:

To describe the process for accepting and taking verbal or telephone medication orders and to prevent errors in communication.

2. DEFINITION(S):

2.1 Verbal Orders - these are orders communicated verbally and directly, by the authorized physician initiating the order to an authorized member of the nursing or clinical staff in an event of an emergency.

Verbal orders are to be used in situations that prevent the authorized individual from entering the order within the required time frame, such as emergency situations.

2.2 Authorized Prescribers- are categories of individuals that are accredited by the hospital: 2.2.1 Physicians 2.2.2 Dentists 2.2.3 Surgeon 2.3 Telephone Orders - are orders given/communicated by the authorized physician initiating the order to a nurse or clinical staff(authorized/ receiving staff) while the physician is outside that area. Maybe outside the hospital or inside the hospital but is allocated in different area. Phone orders should only be used when the ordering individual is unable to directly

enter the order within the required time frame, the order has to be signed by ordering physician within 24 hrs.

2.4 Prescription Drug – is a licensed medicine that is regulated by legislation to

require prescription (written) before it can be obtained.

2.5 Medication Error – any preventable event that may cause or lead to inappropriate medication use or harm to the patient.

2.6 Emergency – a life threatening situation, such as an acute change in vital signs or patient status that will result in rapid deterioration if not treated immediately.

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2.7 Critical state- pathological state which is considered to be life-threatening unless something is done promptly and for which some corrective action could be taken.

2.8 PRN – the medication that must be administered to the patient when needed or when necessary as soon as possible after the STAT order.

3. EQUIPMENT/MATERIAL/FORM(S):

3.1 Patients’ Medical Record (PMR)

3.2 Physician’s Order Form

4. POLICY STATEMENT(S):

4.1 It is the policy of the organization (King Saud Medical City) never to allow verbal or telephone orders for the purpose of medical staff practitioner’s convenience only.

4.2 Whenever possible and practicable, all members of the medical staff with privileges and approval to prescribe medication will do so by physically entering an order in the patient’s medical record, and electronically onto the computer.

4.3 Physician verbal and telephone orders shall be utilized only in emergency situations (life threatening) and in situations where the ordering physician is not available to write the order and delay will result in compromised patient

care. Every effort will be made to minimize the use of verbal orders. No high alert medications shall be ordered verbally or by telephone such as ,chemotherapy drugs, total parenteral nutrition (TPN).

4.4 Telephone and verbal orders for administration of medications may be received and documented by licensed personnel [RN(Registered Nurse)/ RT(Respiratory Therapist-for respiratory medications)/ RM (Registered Midwife)] lawfully authorized to administer drugs. Such orders prescribed verbally or by telephone, are to be issued in the best interest of the patient and therefore will be kept to a minimum. Telephone and verbal orders for medication may be prescribed in the following instances:








4.4.1The prescribing practitioner has determined that the patient is in need of medication within a specific time frame in an urgent or emergent critical situation and he/she is unable to physically write the order in the patient’s medical record due to his/her physical location. The delay in the administration of the medication would not be in the best interest of the patient’s plan of care and treatment, therefore expedient ordering and administration of the medication is necessary.

4.5 To prevent medication errors related to verbal/telephone orders, all individuals licensed and approved by this hospital to receive and record (write down) these types of orders must strictly observe the following practices (mentioned in procedure 5.1) when performing this function.

4.6 Prohibited abbreviations shall not be used in documenting verbal orders or telephone orders.

4.7 All verbal orders accepted by the staff member (registered nurse/midwife/RT) shall be written down(WD), and then read back (RB) in its’ entirety to the prescribing physician at the time the order is given, that the order is “read back” by the receiving registered nurse/midwife.

4.7.1 Exception: In cases of cardio-pulmonary resuscitation (Code Blue) where the order is given first before writing it down , a “repeat back” shall be acceptable. Documentation & encoding of the prescribed medications shall be done by the code blue team leader immediately after the procedure.

4.8 Telephone orders shall be written down and repeatedly read back loudly by the RN (Registered nurse)/RT (Respiratory Therapist)/RM (Registered Midwife).

5. PROCEDURE: 5.1 Verbal and telephone order for medication:

5.1.1 Carry out verbal or telephone orders for medications from the qualified physician , surgeon, dentist, duly licensed or authorized to prescribe by the Saudi Commission of Health Specialties and a member








of the medical staff of this organization. Document the order onto the

physician order sheet form.

5.1.2Include the following criteria (written below) for all verbal and/or telephone orders for medications:

a) Date and time the order is prescribed verbally or via telephone. b) Name of the patient and medical record number.c) Name of prescriber(name of the individual prescribing the drug and

his/her licensure (i.e. (Medical Doctor (MD). d) Drug name (generic name of the drug) e) Drug dosage (exact strength or concentration)/ f) Quantity and/or duration g) Route drug is to be administered h) Frequency of administration

i) Name and level of licensure of the individual receiving and documenting the order.

5.1.3 Inpatient Medications prescribed as PRN must be dispensed in quantities sufficient for 24 hours (according to frequency) unless the prescriber determine otherwise, to ensure continuity of care and prevent patient suffering. The order should include all elements of the prescription (i.e. diagnosis, frequency, duration, route of administration, strength and dosage form) and indication for PRN order.

5.1.4 The licensed nurse/midwife (approved by the medical staff of this hospital) receives and records verbal/ telephone orders. This shall preclude the taking of a verbal order by a specialty technician who are not allowed by law within the scope of his/her responsibility and not approved by the medical staff.

5.1.5 All individuals licensed and approved by this hospital to receive and record verbal/telephone types of orders strictly observes the following

practices when performing this function. The receiver of the order must: obtain all criteria information for medication verbal/telephone orders listed above.(Procedure 5.1.2)








1) Write down the complete verbal and telephone order, and then read it back to the prescriber, receiving confirmation from the prescriber that the order is correct.

2) Read the entire order to the prescriber, spell the name of the drug or requesting the prescriber to spell the drug if the receiver does not know the spelling.

3) Request the generic name of the medication. If the prescriber is unaware of the generic name for a medication prescribed, clarification will be obtained from the pharmacy and it will be recorded on the order.

4) Read back the frequency and/or instructions for use in the non-abbreviated format. Example: If an order is received for BID (twice

daily) frequency, the receiver will read the order to the prescriber as “to be administered twice daily, or two times per day”

5.1.6 All verbal/telephone orders shall be transcribed (recorded) in the metric system, excluding medications/therapies that use standard units such as insulin. The word “unit” shall be written, rather than the abbreviation “U”. For medications prescribed in micrograms, the word “micrograms” will be written, rather than the Latin direction/ symbol microgram (µg).

5.1.7 Document the verbal/telephone order immediately on the patient’s medical record ( physician order form for medication) or, for pharmacists, on a prescription form as appropriate.

a) Indicate either telephone or verbal order in the written record.

b) When entering verbal orders in writing, the receiving person must sign the order in the following manner:

V.O. (Verbal Order) - (Doctor’s name/Clinical staff name, ID or pager number, Title, Date, Time)

c) Sign the written record and indicate level of licensure.

d) The prescribing practitioner must sign the written record of the telephone order within twenty fours (24) hours of giving the order, for

verbal order immediately before leaving the unit.(refer to APP-KSMC- 164-V3-Documentation Requirements.)








5.1.8 The on call in each specialty enters the telephone order onto the electronic system during off shift hours and weekends and the verbal order before the prescriber leaves the unit.

6. RESPONSIBILITY:

It is the responsibility of the Quality Management & Patient Safety Committee, Total Quality Management Department (Policy & Procedure Document & Control Unit), Pharmacy Department, and the Pharmacy & Therapeutics Committee to review (every three years) and monitor the implementation of this policy for effective compliance.

7. REFERENCES:

7.1 1Joint Commission International Accreditation for Hospital, 4th Edition, 1st January 2011, IPSG Goal 2- Improve Effective Communication, page 36 to 37.

7.2 Central Board of Accreditation for Hospital Institutions (PH. 13 – PH.13.2 Standards- Verbal Orders).

7.3 Pharmacy Department DPP-PHD-046 Verbal and Telephone Orders, 2007.

7.4 APP-KSMC-031: Medication Prescribing, November 12, 2007.

7.5 The website at www.hopkinspharmacy.org.staff meetings and departmental newsletter.

7.6 APP-KSMC-008: Prohibited Abbreviations and Symbols, Nov.12, 2007.


http://www.hopkinspharmacy.org.staff/







8. APPROVALS:








NAME TITLE SIGNATURE DATE

Ms. Victoria G. Ramirez

Policy & procedure Section Senior Nurse Coordinator

Ms. Hazel Mary Patient Safety Nurse Coordinator

Reviewed by:

Mr. Mohammad Altaweel PPU Head

Mrs. Celina Eves Chief Nursing Officer

Dr. Khalid Al-Siyabi

Chairman of Pharmaceutical Care Services

Dr. Baleegh Ali

Chairman of Pharmacy and Therapeutics Committee

Dr. Yousef Sharif Acting TQM Director

Dr. Saif Ibrahim

Chairman of Quality & Patient Safety Improvement Council

Approved by: Dr. Haitham Al-Falah Chief Medical Officer

9. POLICY AND PROCEDURE HISTORY:








Initial PP Version 1 APP-KSMC-070-(V1) Dated: 15 January 2008

Replaced by Version 2 APP-KSMC-070-(V2) Dated: 01 December 2010

Replaced by Version 3 APP-KSMC-070-(V3) Dated: 15 August 2012 Replaced by Version 4 APP-KSMC-070-(V4) Dated: 23 Sept. 2015

Deleted Date: __________________________

Replaced by New PP: PP No. &Version______ Dated: _____________


app ksmc 070 v4 tel verbal orders

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