Verbal orders (VOs) are often complex communications that can place patients at risk for harm. The Joint Commission and others have advocated for limiting or ending their use based on such safety concerns. However, VOs also provide a seemingly necessary mechanism to care for patients when providers are in a remote location from a chart or CPOE system. This review outlines the limited research on VOs, provides examples of how they can create quality and safety issues, and explores the root causes of these potential issues. The authors highlight the lack of evidence for VOs contributing to harm and outline a future research agenda to better study this important communication practice. A past AHRQ WebM&M commentary discussed how an unclear VO led to administration of the wrong drug.