Approaches to reducing medication errors have not been uniformly implemented in rural hospitals. This study used direct observation to monitor medication safety in nine small rural hospitals. The authors evaluated the benefits of onsite pharmacy support and bedside bar coding in preventing medication errors. Hospitals with more than 40 hours per week of onsite pharmacy staffing and bedside bar-coding technology had fewer errors than hospitals that had less pharmacist time and no bedside medication bar coding. The most common error types were omission and wrong dose. These findings suggest that increased pharmacy support and bar coding should be implemented in rural acute care settings.