TABLE D-1 Recommendations for the Prevention of Medication Errors in Hospital Care

Recommended Practice

Recommending Body

Strength of Evidence Supporting Efficacy

Technological Interventions

Implement computerized provider order entry (CPOE)

IOM, NCCMERP, MCPME, ASHP, IHI, NQF, PMS, AHRQ

Medium strength

Implement bar coding technology at the point of care

NCCMERP, MCPME, ASHP, PMS, AHRQ

Limited evidence

Ensure availability of pharmaceutical decision support

IOM, MCPME, ASHP

Limited evidence

Use pharmaceutical software

IOM, MCPME, ASHP

Lower strength

Use automated medication dispensing devices

AHRQ

Lower strength

Ensure free-flow protection on all general-use and patient-controlled analgesia (PCA) intravenous (IV) infusion pumps

NCCMERP, JCAHO

Limited evidence

Interventions Utilizing Clinical Pharmacists

Have a central pharmacist supply high-risk IV medications and pharmacy-based admixture systems

IOM, MCPME, PMS

Limited evidence

Include a pharmacist during rounds of patient care units

IOM, MCPME, ASHP, AHRQ

Medium strength

Utilize pharmacist counseling of patients

NCCMERP

Limited evidence

Have a pharmacist available on call after hours of pharmacy operation

MCPME

Medium strength

Have a pharmacist review all medication orders before first doses

ASHP, NQF

Limited evidence

Interventions Related to the Medication-Use Process

Establish a controlled formulary in which the selected medications are based more on safety than on cost

PMS

Limited evidence

Standardize prescription writing and prescription rules, and eliminate certain abbreviations and dose expressions

IOM, NCCMERP, ASHP, IHI, ISMP, NQF, JCAHO, USP

Limited evidence



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