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