​A risk manager recently sought guidance on risks associated with a receptionist receiving verbal orders from providers and giving tests results to patients.

In our response, we note that significant patient safety and liability risks are associated with untrained, unauthorized staff providing test results to patients or handling verbal orders from providers.

Only specifically authorized staff (such as registered nurses or other appropriately trained clinical staff) should receive provider orders. Even then, verbal orders should be used only when absolutely necessary, and should follow specific processes for verbal order verification.

Verbal and telephone orders for medications and medical care are susceptible to error. Consider the environment of a busy clinical setting—caregivers and patients coming and going, multiple conversations under way concurrently, and the sounds of clinical and nonclinical equipment operating. All these factors contribute to the possibility that orders or test results communicated verbally or by telephone will be heard incorrectly or misunderstood. This is particularly true with orders for medications that have sound-alike drug names.

When it is highly impractical or impossible for the prescriber to write down orders or enter orders into an electronic system at the time they are given, verbal or telephone orders may be the only available alternative. The receiver of the order is expected to write down a verbal or telephone order as it is given and to read back the information as it is written for confirmation.

Methods to demonstrate that the verbal order was written down and read back vary among healthcare organizations. Some opt to have the receiver of the orders document "verbal order read-back" in the patient medical record, while others use forms designed to capture the verbal order read-back process with a check-off and signature. In the case of electronic records, a keystroke or additional screen notation can be used. Compliance with the read-back process must be monitored through observation and/or record audits. According to the Centers for Medicare and Medicaid Services, at 42 CFR § 482.24(c)(2), in accordance with hospital policy and state and federal regulations, the ordering practitioner must promptly verify, sign, date, and time the order.

Resources for verbal orders include the American Health Information Management Association's (AHIMA) Verbal/Telephone Order Authentication and Time Frames and the Institute for Safe Medication Practices' Despite Technology, Verbal Orders Persist, Read Back Is Not Widespread, and Errors Continue (see "Recommendations" and "Organizational Policies and Procedures").

Test results should be given to patients only by providers or specifically authorized staff (such as registered nurses or other appropriately trained clinical staff) who are functioning under the guidance of providers, and in adherence to organizational policies and procedures regarding communication of test results.

Ultimately, the ordering provider is responsible for reviewing and acting on diagnostic test results and referrals and for documenting that these steps have been taken. However, systemic issues at the practice level may make test and referral tracking difficult and very time-consuming for providers and staff. A best practice is to ensure that consistent, reliable tracking processes are in place at an organizational level and that all involved staff adhere to these processes. Risk managers working to resolve test tracking concerns should focus on office systems rather than on the performance of individual staff members.

Test and referral tracking systems can differ from one practice to another because of variations in electronic health record (EHR) capabilities, differences in how outside records are received and processed and in how interoffice communications work, and other factors. Most importantly, practices should have policies and procedures in place that consistently "close the loop" on test and referral tracking. Patients and caregivers should also take an active role in closing this loop; practices should encourage them to contact the office or access the patient portal to obtain test results and referral information if they do not receive them in a timely fashion.

Test tracking resources include the Agency for Healthcare Research and Quality's Improving Your Laboratory Testing Process and the toolkit Closing the Referral Loop from PCPI (the Physician Consortium for Performance Improvement) and the Wright Center for Graduate Medical Education. Clinical Risk Management Program users can also refer to the Test Tracking and Follow-Up Toolkit.

The recommendations contained in Ask ECRI do not constitute legal advice. Facilities should consult legal counsel for specific guidance and develop clinical guidance in consultation with their clinical staff.