Safety matters: Medication overrides and verbal orders

Yale New Haven’s Accreditation and Regulatory Affairs department has identified opportunities for improvement in the areas below as part of the health system’s continuous readiness for regulatory preparedness and surveys. 

Medication overrides

Overridable medications are those required in urgent or emergent clinical situations when the minimal delay for a provider to place and/or to have a pharmacist verify the order would result in patient harm. The decision to override a medication depends on the situation and should not be based solely on whether the medication can be overridden. Errors that might occur with medication overrides include: 

• Wrong patient
• Wrong medication, concentration, dose
• Wrong dosage form (immediate release when sustained release is intended)
• Wrong route or rate of infusion

Clinicians completing overrides or administering the medications are responsible for performing a manual assessment of factors that include (bur are not limited to):

• Drug-allergy interactions
• Drug-drug interactions
• Drug-disease state interactions (such as renal dysfunction)
• Dose calculations to support medication administration
• Other relevant administration instructions

After administering the medication, the clinician should link the override pull transaction on the MAR (magenta bar) to the provider’s order, where possible, using “Tip Sheet: Epic, Override Pulls Workflow” (located under the Tip Sheet tab in Epic).

If the situation doesn’t warrant override workflow, but verification is delaying medication access, contact the covering pharmacist for order verification.

Verbal orders 

Use verbal and telephone orders only when entering orders into the electronic medical record (EMR) is not practicable. Verbal orders should be used only when providers are in the operating room or procedural suites or during emergent circumstances when a delay would compromise patient care. Telephone orders are taken only when the prescriber is not physically present; EMR entry is not practicable (such as non-formulary or restricted category medications); or in situations requiring immediate attention. Orders are not accepted via text or electronic messages.

The person accepting verbal or telephone orders enters them into the EMR before acting on the order unless the clinical situation necessitates acting before entering the order. When handling verbal orders, use CHAMP behaviors to ensure clear communication: 

• Repeat back/read back the information
• Ask clarifying questions
• Use phonetic and numeric clarifications 

For more information about these or other regulatory focus topics, contact your Accreditation and Regulatory Affairs liaison. Contact information is on the employee intranet.