If a nurse receives a verbal order and subsequently calls it to the pharmacy, there is even more room for error. The pharmacist must rely on the accuracy of the nurse's written transcription of the order and the pronunciation when it is read to the pharmacist. Sound-alike drug names also impact the accuracy of verbal orders. There are literally thousands of name pairs that can easily be misheard. Drug names are not the only information prone to misinterpretation.
Numbers are also easily misheard.
However, it is very unlikely that they will ever be totally eliminated. Please distribute the following guidelines to nurses, pharmacists, and physicians in your facility to stimulate discussion. While we are aware that all of the suggestions may not be feasible in your organization, they can help you evaluate your current practices. Prescribers must enunciate verbal orders clearly and the receiver should always repeat the order to the prescriber to avoid misinterpretation. This step is absolutely essential and should become habit even if the receiver is confident that he or she has initially heard the order correctly.