Verbal medication orders in the OR

Medication errors are the fourth most commonly reported sentinel event, and changes in practice are needed to provide a safe environment for patients in the OR. Existing measures for preventing medication errors in the OR have focused on labeling medication containers on and off the sterile field. Very little attention, however, has been given to the potential for errors caused by verbal orders in the OR or to developing processes to prevent such errors. Simple solutions for improving the safety of verbal medication orders include instituting a read-back system in which verbal orders are written on a dry-erase board and verified by the ordering physician, requesting clarification of questionable orders, and reducing distractions in the OR.