Verbal Prescriptions: Best Practices for Clarity and Safety in Healthcare

When a doctor calls out a medication order over the phone or in a busy ER, lives hang in the balance. Verbal prescriptions aren’t just a convenience-they’re often a necessity. But they’re also one of the most dangerous moments in patient care. A single misheard word can mean the difference between healing and harm. In 2025, despite all the advances in electronic systems, verbal prescriptions still make up 10-15% of medication orders in hospitals and up to 25% in clinics. And the errors? They’re not rare. They’re predictable.

Why Verbal Prescriptions Are Still Necessary

You might think we’d have eliminated verbal orders by now. After all, electronic prescribing cuts errors by up to 90%. But in real-world medicine, technology doesn’t always keep up with urgency. Surgeons operating in sterile fields can’t pull out tablets. Paramedics en route to the hospital need to order epinephrine before arrival. A nurse in the NICU might need to confirm a dose while holding a trembling newborn. These aren’t edge cases-they’re daily realities.

The Institute for Safe Medication Practices says it plainly: “The only real record of a verbal order is in the memories of those involved.” That’s terrifying when you consider how easily memories fail. A 2021 Medscape survey found 68% of nurses had at least one near-miss every month due to unclear speech. Sometimes it’s a mumbled “fifteen” instead of “five.” Other times, it’s “Hydralazine” mistaken for “Hydroxyzine”-two drugs with wildly different effects. One lowers blood pressure. The other treats anxiety. Give the wrong one to a premature infant, and the result can be fatal.

The Core Rules: What Every Provider Must Do

There’s no magic trick to making verbal prescriptions safe. Just discipline. And a few non-negotiable steps that every clinician, nurse, and pharmacist must follow-every single time.

• Read-back is mandatory. The person receiving the order must repeat it back word-for-word. Not “I think it was ampicillin, 200 mg.” Not “Was it once or twice a day?” Full repetition: “Ampicillin, spelled A-M-P-I-C-I-L-L-I-N, two hundred milligrams, intravenous, every six hours, for suspected sepsis. Prescribed by Dr. Patel.”
• Spell everything phonetically. Never say “Zyprexa.” Say “Z-Y-P-R-E-X-A.” Never say “Celexa.” Say “C-E-L-E-X-A.” Sound-alike drugs like Celebrex and Celexa, Zyrtec and Zyprexa, have caused dozens of documented deaths. Spelling it out removes ambiguity.
• State numbers twice. Say “fifteen milligrams,” then “one-five milligrams.” This prevents confusion between 15 and 5, or 50 and 5. In high-stakes settings, this single step has prevented overdoses.
• Avoid all abbreviations. No “BID,” no “QID,” no “PO,” no “IV.” Say “twice daily,” “four times daily,” “by mouth,” “intravenous.” Abbreviations are the #1 source of misinterpretation.
• Never give multiple orders at once. One drug. One dose. One route. One frequency. Period. Trying to rush through three orders during a shift change? That’s how a baby gets the wrong antibiotic. The Pennsylvania Patient Safety Authority documented this exact error in 2006-and it still happens.

High-Risk Medications: When Verbal Orders Are Forbidden

Not all drugs should ever be ordered verbally. Some are too dangerous. The Pennsylvania Patient Safety Authority and the Washington State Department of Health both prohibit verbal orders for chemotherapy unless it’s to hold or stop treatment. Insulin, heparin, and opioids? Same rule. In non-emergencies, these must be ordered electronically or via written form.

Why? Because the margin for error is microscopic. A 10-fold overdose of insulin? That’s not a mistake-it’s a death sentence. A nurse in Bristol told me about a case where a patient received 10 units of insulin instead of 1 because the prescriber said “ten” without spelling it out. The patient went into a coma. They survived, but only because the nurse double-checked the chart.

Even in emergencies, the rules tighten. If you must give a verbal order for an opioid, you must state the exact dose, route, and indication. And you must document it within 30 minutes-not two hours, not the next shift. Johns Hopkins requires authentication by the end of the same shift. No exceptions.

Who’s Responsible? Everyone.

This isn’t just the doctor’s job. It’s the nurse’s. The pharmacist’s. The unit clerk’s. A 2020 Joint Commission survey found 63% of nurses said some prescribers refuse to accept read-backs. “It’s too slow,” they say. “I’m busy.” But safety isn’t optional. When a nurse skips the read-back because “I know what he meant,” that’s not experience-that’s recklessness.

The American Nurses Association’s 2022 survey showed 87% of nurses support mandatory read-back protocols. Yet only 58% say they’re consistently followed in their unit. Why? Pressure. Burnout. Poor training. One ER nurse told me: “I’ve had to remind five different doctors this week to spell out drug names. One of them got mad. But I’d rather get yelled at than bury a patient.”

Documentation: The Only Permanent Record

A verbal order isn’t official until it’s written down. And not just scribbled on a sticky note. It must be entered directly into the electronic health record with:

• Patient’s full name and date of birth
• Medication name spelled out
• Dose with units (e.g., “5 milligrams,” not “5 mg”)
• Route (intravenous, oral, subcutaneous)
• Frequency (twice daily, every 8 hours)
• Indication (e.g., “for acute pain,” “for atrial fibrillation”)
• Name and credentials of the prescriber
• Exact time and date the order was received
• Exact time and date the order was authenticated

CMS requires authentication within 48 hours. But leading hospitals like Mayo Clinic and Kaiser Permanente require it before the shift ends. Why? Because if you wait, the order gets lost. Or worse-someone else assumes it’s already done.

What Happens When You Skip the Steps?

The 2006 NICU case is still taught in medical schools. A premature infant was being transferred. The on-call doctor gave a verbal order for two antibiotics: ampicillin 200 mg and gentamicin 5 mg, both IV. The nurse wrote down “ampicillin 200 mg IV” and “gentamicin 5 mg IV.” But the doctor had meant 20 mg of gentamicin. The nurse didn’t ask for clarification. The baby got five times the correct dose. Within hours, the infant developed kidney failure. They survived-but with permanent damage.

That’s not an outlier. A 2023 ECRI Institute report found that 42% of verbal order errors happen during shift changes. That’s when fatigue hits. When handoffs are rushed. When someone says, “I’ll get to it later.”

What’s Changing? And What’s Next

The good news? Verbal orders are declining. In 2006, they made up 22% of hospital orders. Today, it’s 10-15%. Why? CPOE systems. Voice-to-text tech. Better EHR integration. KLAS Research predicts by 2025, they’ll drop to 5-8%.

But here’s the truth: they’ll never disappear. Not while we have trauma bays, operating rooms, and ambulances. Dr. Robert Wachter wrote in NEJM Catalyst in 2023: “Certain clinical scenarios will always require verbal communication, making safety protocols permanently necessary.”

The FDA is now working on standardizing how high-risk drug names are pronounced. ISMP Canada’s 2020 guidelines are becoming national policy. Forty-two states now require read-back verification by law. That’s progress.

Final Rule: When in Doubt, Stop

The most powerful tool in verbal prescribing isn’t a checklist. It’s a mindset. If something doesn’t sound right-stop. Ask again. Spell it. Confirm. Don’t be embarrassed. Don’t assume. Don’t rush.

One nurse in a Reddit thread summed it up: “I once stopped a 10-fold hydralazine error because I asked, ‘Did you mean H-Y-D-R-A-L-A-Z-I-N-E?’ The doctor said yes. Then he paused. ‘Wait… I meant hydroxyzine.’ We caught it. He thanked me. I didn’t get a medal. But the patient went home.”

Verbal prescriptions aren’t going away. But the mistakes? They’re preventable. Every time you follow the rules, you’re not just following protocol. You’re saving a life.