“Roger That!” Roger What?

Added on Sep 11, 2015

Hospital Safety Procedures

One Sunday afternoon during the summer, I found myself at an emergency care center with a relative. As we waited for our turn to see the doctor, I sensed that there must have been a lot of mishaps at the local swimming pools that day, as we saw lots of parents and children coming into the emergency care center in swimsuits and cover-ups. I took notice of a young girl, about 10 or 11 years old who had broken her arm. Not long after she arrived, I overheard her nurse say to the ED physician, “Hey – how about a little cocktail for the kid in Five – she’s about to go to X-ray.” The physician gave the nurse a verbal order for narcotics to which she replied “Roger that.” Although the medication dose sounded appropriate, my safety antenna went up immediately. Not only had there been no proper patient identification, the physician had given a verbal order inappropriately (this was not an emergency situation) and no confirmation of the communication was issued by the nurse.

When staff fail to follow rules and policies, they often do so with the best of intentions. For me, it was easy to understand why the nurse did what she did in this particular situation. Her patient was on her way to X-ray with a painful arm and she knew it was going to be moved and manipulated during the X-ray procedure, therefore she wanted to ensure that her patient would be as comfortable and pain free as possible. However, prioritizing comfort or satisfaction ahead of safety can lead to events of harm.

Healthcare regulators have placed limits on when verbal and telephone orders can be used AND require read-backs for good reason. When a sender communicates something verbally he or she assumes that the receiver understands the message correctly. However, only the sender can confirm that the receiver heard the message correctly. If confirmation is only verbal, the receiver must then rely on their memory in acting upon the communication – another opportunity for error. In one study – researchers found an error rate of 9.1% when there was no read-back of verbal orders.1

A good read-back is a three-step process:

  • 1. The sender sends a message to the receiver
  • 2. The receiver writes down the information and reads it back
  • 3. The sender acknowledges that information was received correctly by stating: “That’s correct” (or corrects any inaccuracies).


As far as I know, the young lady’s treatment went off without a hitch and I do applaud the care team’s concern for managing her pain. I just wish that managing that pain safely was a little higher on their priority list.