Communication is commonly cited as a contributing factor to adverse events causing patient harm (Baker et al., 2004). There are numerous ways and reasons that communication failures can occur, such as poor handwriting, transcription errors, lack of verification, lack of integration of information, and ineffective team functioning. Errors that can occur in critical care with the verbal communication and receipt of a telephone order will be highlighted. These examples, together with proposed strategies for improving telephone order safety, are intended to promote awareness and potential practice changes in the critical care environment.