Recommended Practice

Recommending Body

Strength of Evidence Supporting Efficacy

Improve the work environment for medication preparation, dispensing, and administration

IOM, ASHP, IHI, NQF

Limited evidence

Improve error detection and reporting, and promote a nonpunitive atmosphere

NCCMERP, MCPME, ASHP, NQF, PMS

Limited evidence

Make relevant patient information available at the point of care

IOM, MCPME, IHI

Indirectly supported through evidence on CPOE, electronic medication administration record (MAR), and bar coding

Use failure modes and effects analysis or other strategies for risk management

NCCMERP, PMS, ISMP

Limited evidence

Improve patients’ knowledge about their treatment

IOM, MCPME, IHI, PMS

Limited evidence

NOTE: AHRQ = Agency for Healthcare Research and Quality; ASHP = American Society of Hospital Pharmacists; IHI = Institute for Healthcare Improvement; IOM = Institute of Medicine; ISMP = Institute for Safe Medication Practices; JCAHO = Joint Commission on Accreditation of Healthcare Organizations; MCPME = Massachusetts Coalition for the Prevention of Medical Errors; NCCMERP = National Coordinating Council for Medication Error Reporting and Prevention; NQF = National Quality Forum; PMS = Pathways for Medication Safety; USP = U.S. Pharmacopeia.

SOURCE: ASHP, 1993; No Author, 1996; MCPME, 1999; IOM, 2000; Shojania et al., 2001; PMS, 2002; NQF, 2003; IHI, 2005; ISMP, 2005b; JCAHO, 2005a; NCCMERP, 2005b.

recommend implementing computerized provider order entry (CPOE) and bar coding at the bedside, although the evidence supporting bar coding remains weak. Other specific interventions supported by multiple groups include involving clinical pharmacists in patient rounds, implementing and utilizing unit dosing, standardizing prescription writing and prescription rules and eliminating certain abbreviations, utilizing special written protocols for high-risk medications, and limiting as well as standardizing verbal medication orders. Additional general recommendations embraced by most organizations include adopting a systems-oriented approach to medication errors, creating a culture of safety, and improving medication error identification and reporting.

For studies of interventions to reduce medication errors, inclusion criteria derived from AHRQ-sponsored analysis of patient safety practices were used (Shojania et al., 2001). Only studies with the following study design



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