Continuing education online courses in Preventing Medication Errors.

Professor Rudolf Klimes, PhD, welcomes you to this online course. 

START the course here. TAKE the exam at the end. 

Course Outline

1. Preventing Medical Errors: An epidemic of errors, where do they occur, their costs, associated fears, the system problem.
2. Improving Patient Safety: Match needs with capacity, have clear communication, specific setting for care, assigned work-spaces.
3. Types of Medication Errors: categories of errors, patients at risk, and how do errors happen.
4. Preventing Medication Errors: prevention via prescriptions, regulations, classification, labeling, and tracking.
5. Reporting Medication Errors: computerized systems, using report data, evaluation of safety, charting, administrative databases,claims, and audits.

P12  Preventing Medication Errors.  3 CE course hours

What’s wrong with this picture? The strength looks different for one of these medications, even though all mean the same thing—5 mg. The problem is that one of them uses an unnecessary zero after the decimal point. Sometimes prescriptions are written this way and the decimal point can be missed, leading to a tenfold overdose (50 mg instead of 5 mg). This is one example of a potential preventable medication error.

1. Preventing Medical Errors

One in seven Medicare patients in hospitals experience a medical error. But medical errors can occur anywhere in the health care system: In hospitals, clinics, surgery centers, doctors’ offices, nursing homes, pharmacies, and patients’ homes. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal.

Source: Agency for Healthcare Research and Quality

An Epidemic of Errors

Medical Errors: The Scope of the Problem

Fact sheet, Publication No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/errback.htm

An Epidemic of Errors: An Overview

The November 1999 report of the Institute of Medicine (IOM), entitled To Err Is Human: Building A Safer Health System, focused a great deal of attention on the issue of medical errors and patient safety. The report indicated that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors.

Even using the lower estimate, this would make medical errors the eighth leading cause of death in this country—higher than motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516). About 7,000 people per year are estimated to die from medication errors alone—about 16 percent more deaths than the number attributable to work-related injuries.

The President ordered the Quality Interagency Coordination Task Force to make recommendations on improving health care quality and protecting patient safety in response to the IOM report. The Report to the President on Medical Errors was issued in February 2000. For more information on medical errors, select http://www.ahrq.gov/qual/errorsix.htm.

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[1.1]  Where Errors Occur

Errors occur not only in hospitals but in other health care settings, such as physicians’ offices, nursing homes, pharmacies, urgent care centers, and care delivered in the home. Unfortunately, very little data exist on the extent of the problem outside of hospitals. The IOM report indicated, however, that many errors are likely to occur outside the hospital. For example, in a recent investigation of pharmacists, the Massachusetts State Board of Registration in Pharmacy estimated that 2.4 million prescriptions are filled improperly each year in the State.

[1.2] Costs

Medical errors carry a high financial cost. The IOM report estimates that medical errors cost the Nation approximately $37.6 billion each year; about $17 billion of those costs are associated with preventable errors. About half of the expenditures for preventable medical errors are for direct health care costs.

Not a New Issue

The serious problem of medical errors is not new, but in the past, the problem has not gotten the attention it deserved. A body of research describing the problem of medical errors began to emerge in the early 1990s with landmark research conducted by Lucian Leape, M.D., and David Bates, M.D., and supported by the Agency for Health Care Policy and Research, now the Agency for Healthcare Research and Quality (AHRQ).

The final report of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, released in 1998, identified medical errors as one of the four major challenges facing the Nation in improving health care quality. Based on the recommendations of that report, President Clinton directed the establishment of the Quality Interagency Coordination Task Force (QuIC) to coordinate quality improvement activities in Federal health care programs.

The QuIC includes: the Departments of Health and Human Services, Labor, Veterans Affairs, Commerce, and Defense; the Coast Guard; the Bureau of Prisons; and the Office of Personnel Management.

[1.3]  Public Fears

While there has been no unified effort to address the problem of medical errors and patient safety, awareness of the issue has been growing. Americans have a very real fear of medical errors. According to a national poll conducted by the National Patient Safety Foundation:

• Forty-two percent of respondents had been affected by a medical error, either personally or through a friend or relative.
• Thirty-two percent of the respondents indicated that the error had a permanent negative effect on the patient’s health.

Overall, the respondents to this survey thought the health care system was “moderately safe” (rated a 4.9 on a 1 to 7 scale, where 1 is not safe at all and 7 is very safe).

Another survey, conducted by the American Society of Health-System Pharmacists, found that Americans are “very concerned” about:

• Being given the wrong medicine (61 percent).
• Being given two or more medicines that interact in a negative way (58 percent).
• Complications from a medical procedure (56 percent).

Most people believe that medical errors are the result of the failures of individual providers. When asked in a survey about possible solutions to medical errors:

• Seventy-five percent of respondents thought it would be most effective to “keep health professionals with bad track records from providing care.”
• Sixty-nine percent thought the problem could be solved through “better training of health professionals.”

This fear of medical errors was borne out by the interest and attention that the IOM report generated. According to a survey by the Kaiser Family Foundation, 51 percent of Americans followed closely the release of the IOM report on medical errors.

[1.4] It’s a Systems Problem

The IOM emphasized that most of the medical errors are systems related and not attributable to individual negligence or misconduct. The key to reducing medical errors is to focus on improving the systems of delivering care and not to blame individuals. Health care professionals are simply human and, like everyone else, they make mistakes. But research has shown that system improvements can reduce the error rates and improve the quality of health care:

• A 1999 study indicated that including a pharmacist on medical rounds reduced the errors related to medication ordering by 66 percent, from 10.4 per 1,000 patient days to 3.5 per 1,000 patient days.
• The specialty of anesthesia has reduced its error rate by nearly sevenfold, from 25 to 50 per million to 5.4 per million, by using standardized guidelines and protocols, standardizing equipment, etc.
• One hospital in the Department of Veterans Affairs uses hand-held, wireless computer technology and bar-coding, which has cut overall hospital medication error rates by 70 percent. This system is soon to be implemented in all VA hospitals.

[1.5] Types of Errors

The IOM defines medical error as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” An adverse event is defined as “an injury caused by medical management rather than by the underlying disease or condition of the patient.” Some adverse events are not preventable and they reflect the risk associated with treatment, such as a life-threatening allergic reaction to a drug when the patient had no known allergies to it. However, the patient who receives an antibiotic to which he or she is known to be allergic, goes into anaphylactic shock, and dies, represents a preventable adverse event.

Most people believe that medical errors usually involve drugs, such as a patient getting the wrong prescription or dosage, or mishandled surgeries, such as amputation of the wrong limb. However, there are many other types of medical errors, including:

• Diagnostic error, such as misdiagnosis leading to an incorrect choice of therapy, failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results.
• Equipment failure, such as defibrillators with dead batteries or intravenous pumps whose valves are easily dislodged or bumped, causing increased doses of medication over too short a period.
• Infections, such as nosocomial and post-surgical wound infections.
• Blood transfusion-related injuries, such as giving a patient the blood of the incorrect type.
• Misinterpretation of other medical orders, such as failing to give a patient a salt-free meal, as ordered by a physician.

[1.6] Preventing Errors

Research clearly shows that the majority of medical errors can be prevented:

• One of the landmark studies on medical errors indicated 70 percent of adverse events found in a review of 1,133 medical records were preventable; 6 percent were potentially preventable; and 24 percent were not preventable.
• A study released last year, based on a chart review of 15,000 medical records in Colorado and Utah, found that 54 percent of surgical errors were preventable.

Other potential system improvements include:

• Use of information technology, such as hand-held bedside computers, to eliminate reliance on handwriting for ordering medications and other treatment needs.
• Avoidance of similar-sounding and look-alike names and packages of medication.
• Standardization of treatment policies and protocols to avoid confusion and reliance on memory, which is known to be fallible and responsible for many errors.

Source: Medical Errors: The Scope of the Problem. Fact sheet, Publication No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/errback.htm

Source: 30 Safe Practices for Better Health Care: Fact Sheet. March 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/factsheets/errors-safety/30safe/30-safe-practices.html

3. Types of Medication  Errors

Classification of Medication Errors

The best way to understand how medication errors happen and how to prevent them is to consider their classification, which can be contextual, modal, or psychological. Contextual classification deals with the specific time, place, medicines, and people involved. Modal classification examines the ways in which errors occur (e.g. by omission, repetition, or substitution). However, classification based on psychological theory is to be preferred, as it explains events rather than merely describing them. Its disadvantage is that it concentrates on human rather than systems sources of errors. These classifications have been discussed in detail elsewhere.

Psychologists consider an error to be a disorder of an intentional act, and they distinguish between errors in planning an act and errors in its execution. If a prior intention to reach a specified goal leads to action, and the action leads to the goal, all is well. If the plan of action contains some flaw, that is a ‘mistake’. If a plan is a good one but is badly executed, that is a failure of skill.

This approach yields four broad types of medication error. Mistakes can be divided into (i) knowledge-based errors and (ii) rule-based errors. Failures of skill can be divided into (iii) action-based errors (‘slips’, including technical errors) and (iv) memory-based errors (‘lapses’).

Knowledge-based errors can be related to any type of knowledge, general, specific, or expert. It is general knowledge that penicillins can cause allergic reactions; knowing that your patient is allergic to penicillin is specific knowledge; knowing that co-fluampicil contains penicillins is expert knowledge. Ignorance of any of these facts could lead to a knowledge-based error.

Rule-based errors can further be categorized as (a) the misapplication of a good rule or the failure to apply a good rule; and (b) the application of a bad rule.

An action-based error is defined as ‘the performance of an action that was not what was intended. A slip of the pen, when a doctor intends to write diltiazem but writes diazepam, is an example. Technical errors form a subset of action-based errors. They have been defined as occurring when ‘an outcome fails to occur or the wrong outcome is produced because the execution of an action was imperfect’. An example is the addition to an infusion bottle of the wrong amount of drug.

Memory-based errors occur when something is forgotten; for example, giving penicillin, knowing the patient to be allergic, but forgetting.

Source: Aronson, Jeffrey K. Medication errors: definitions and classification

Errors have been classified as errors, mistakes, slips, violated rules, unperformed actions, and  lapses.

The classification of medication errors based on a psychological approach
Wolters Kluwer Health/Adis©; Adis Data Information BV (2006) Source

Reducing Medication Errors

Strategies to Reduce Medication Errors:
Working to Improve Medication Safety

U.S. Food and Drug Administration

When Jacquelyn Ley shattered her elbow on the soccer field, her parents set out to find her the best care in Minneapolis. “We drove past five other hospitals to get to the one we wanted,” says Carol Ley, M.D., an occupational health physician. Her husband, an orthopedic surgeon, made sure Jacquelyn got the right surgeon. After a successful three-hour surgery to repair the broken bones, Jacquelyn, who was 9 at the time, received the pain medicine morphine through a pump and was hooked up to a heart monitor, breathing monitor, and blood oxygen monitor. Her recovery was going so well that doctors decided to turn off the morphine pump and to forgo regular checks of her vital signs.

Carol Ley slept in her daughter’s hospital room that night. When she woke up in the middle of the night and checked on her, Jacquelyn was barely breathing. “I called her name, but she wouldn’t respond,” she says. “I shook her and called for help.” The morphine pump hadn’t been shut down, but had accidentally been turned up high. The narcotic flooded Jacquelyn’s body. She survived the overdose, but it was a close call. “If three more hours had gone by, I don’t think Jacquelyn would have survived,” Ley says. “Fortunately, I woke up.”

Ley was pleased with the way the hospital handled the error. “They came right out and said the morphine pump was incorrectly programmed, they told me the steps they were going to take to make sure Jacquelyn was OK, and they also told me what they were going to do to make sure this kind of mistake won’t happen again. And that’s very important to me.” The hospital began using pumps that are easier to use and revamped nurses’ training. Ley believes there were many contributors to the error, including the fact that it was Labor Day weekend and there were staff shortages. “It goes to show that this can happen to anyone, anywhere,” says Ley, who now chairs the board of the National Patient Safety Foundation.

Multiple Factors

Since 1992, the Food and Drug Administration has received nearly 30,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher. There is no “typical” medication error, and health professionals, patients, and their families are all involved. Some examples:

A physician ordered a 260-milligram preparation of Taxol for a patient, but the pharmacist prepared 260 milligrams of Taxotere instead. Both are chemotherapy drugs used for different types of cancer and with different recommended doses. The patient died several days later, though the death couldn’t be linked to the error because the patient was already severely ill.

An older patient with rheumatoid arthritis died after receiving an overdose of methotrexate–a 10-milligram daily dose of the drug rather than the intended 10-milligram weekly dose. Some dosing mix-ups have occurred because daily dosing of methotrexate is typically used to treat people with cancer, while low weekly doses of the drug have been prescribed for other conditions, such as arthritis, asthma, and inflammatory bowel disease.

One patient died because 20 units of insulin was abbreviated as “20 U,” but the “U” was mistaken for a “zero.” As a result, a dose of 200 units of insulin was accidentally injected.
A man died after his wife mistakenly applied six transdermal patches to his skin at one time. The multiple patches delivered an overdose of the narcotic pain medicine fentanyl through his skin.

A patient developed a fatal hemorrhage when given another patient’s prescription for the blood thinner warfarin.

These and other medication errors reported to the FDA may stem from poor communication; misinterpreted handwriting; drug name confusion; confusing drug labels, labeling, and packaging; lack of employee knowledge; and lack of patient understanding about a drug’s directions. “But it’s important to recognize that such errors are due to multiple factors in a complex medical system,” says Paul Seligman, M.D., director of the FDA’s Office of Pharmacoepidemiology and Statistical Science. “In most cases, medication errors can’t be blamed on a single person.”

A medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention. The council, a group of more than 25 national and international organizations, including the FDA, examines and evaluates medication errors and recommends strategies for error prevention.

A Regulatory Approach

The public took notice in 1999 when the Institute of Medicine (IOM) released a report, “To Err is Human: Building a Safer Health System.” According to the report, between 44,000 and 98,000 deaths may result each year from medical errors in hospitals alone. And more than 7,000 deaths each year are related to medications. In response to the IOM’s report, all parts of the U.S. health system put error reduction strategies into high gear by re-evaluating and strengthening checks and balances to prevent errors.

In addition, the U.S. Department of Health and Human Services (HHS) and other federal agencies formed the Quality Interagency Coordination Task Force in 2000 and issued an action plan for reducing medical errors. In 2001, former HHS Secretary Tommy G. Thompson announced a Patient Safety Task Force to coordinate a joint effort to improve data collection on patient safety. The lead agencies are the FDA, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and the Agency for Healthcare Research and Quality.

The FDA enhanced its efforts to reduce medication errors by dedicating more resources to drug safety, which included forming a new division on medication errors at the agency in 2002. “FDA works to prevent medication errors before a drug reaches the market and monitors any errors that may occur after that,” says Jerry Phillips, R.Ph., former director of the FDA’s Division of Medication Errors and Technical Support.

Here’s a look at key areas in which the FDA is working to reduce medication errors.

Bar code label rule: After a public meeting in July 2002, the FDA decided to propose a new rule requiring bar codes on certain drug and biological product labels. Health care professionals would use bar code scanning equipment, similar to that used in supermarkets, to make sure that the right drug in the right dose and route of administration is given to the right patient at the right time.

“It’s a promising way to automate aspects of medication administration,” says Robert Krawisz, former executive director of the National Patient Safety Foundation. “The technology’s impact at VA hospitals so far has been amazing.” The Department of Veterans Affairs (VA) already uses bar codes nationwide in its hospitals, and the result has been a drastic reduction in medication errors. For example, the VA medical center in Topeka, Kan., has reported that bar coding reduced its medication error rate by 86 percent over a nine-year period.

Here’s how it works: When patients enter the hospital, they get a bar-coded identification wristband that can transmit information to the hospital’s computer, says Lottie Lockett, R.N., a nursing administrator at the Houston VA Medical Center. Nurses have laptop computers and scanners on top of medication carts that they bring to patients’ rooms. Nurses use the scanners to scan the patient’s wristband and the medications to be given. The bar codes provide unique, identifying information about drugs given at the patient’s bedside. “Before giving medications, nurses use the scanner to pull up a patient’s full name and social security number on the laptops, along with the medications,” Lockett says. “If there is not a match between the patient and the medication or some other problem, a warning box pops up on the screen.”

The FDA’s final rule on bar code labeling was published on Feb. 26, 2004. The rule, which took effect on April 26, 2004, applies to prescription drugs, biological products (other than blood, blood components, and devices regulated by the Center for Biologics Evaluation and Research), and over-the-counter (OTC) drugs that are commonly used in hospitals. Manufacturers, repackers, relabelers, and private label distributors of prescription and OTC drugs would be subject to the bar code requirements. The agency continues to study whether it also should develop a rule requiring bar code labeling on medical devices.

Drug name confusion: To minimize confusion between drug names that look or sound alike, the FDA reviews about 300 drug names a year before they are marketed. “About one-third of the names that drug companies propose are rejected,” says Phillips. The agency tests drug names with the help of about 120 FDA health professionals who volunteer to simulate real-life drug order situations. “FDA also created a computerized program that assists in detecting similar names and that will help take a more scientific approach to comparing names,” Phillips says.

After drugs are approved, the FDA tracks reports of errors due to drug name confusion and spreads the word to health professionals, along with recommendations for avoiding future problems. For example, the FDA has reported errors involving the inadvertent administration of methadone, a drug used to treat opiate dependence, rather than the intended Metadate ER (methylphenidate) for the treatment of attention-deficit/hyperactivity disorder (ADHD). One report involved the death of an 8-year-old boy after a possible medication error at the dispensing pharmacy. The child, who was being treated for ADHD, was found dead at home. Methadone substitution was the suspected cause of death. Some FDA recommendations regarding drug name confusion have encouraged pharmacists to separate similar drug products on pharmacy shelves and have encouraged physicians to indicate both brand and generic drug names on prescription orders, as well as what the drug is intended to treat.

The last time the FDA changed a drug name after it was approved was in 2004 when the cholesterol-lowering medicine Altocor was being confused with the cholesterol-lowering medicine Advicor. Now Altocor is called Altoprev, and the agency hasn’t received reports of errors since the name change. Other examples of drug name confusion reported to the FDA include:

• Serzone (nefazodone) for depression and Seroquel (quetiapine) for schizophrenia
• Lamictal (lamotrigine) for epilepsy, Lamisil (terbinafine) for nail infections, Ludiomil (maprotiline) for depression, and Lomotil (diphenoxylate) for diarrhea
• Taxotere (docetaxel) and Taxol (paclitaxel), both for chemotherapy
• Zantac (ranitidine) for heartburn, Zyrtec (cetirizine) for allergies, and Zyprexa (olanzapine) for mental conditions
• Celebrex (celecoxib) for arthritis and Celexa (citalopram) for depression.

Drug labeling: Consumers tend to overlook important label information on OTC drugs, according to a Harris Interactive Market Research Poll conducted for the National Council on Patient Information and Education and released in January 2002. In May 2002, an FDA regulation went into effect that aims to help consumers use OTC drugs more wisely.

The regulation requires a standardized “Drug Facts” label on more than 100,000 OTC drug products. Modeled after the Nutrition Facts label on foods, the label helps consumers compare and select OTC medicines and follow instructions. The label clearly lists active ingredients, uses, warnings, dosage, directions, other information, such as how to store the medicine, and inactive ingredients.

As for health professionals, the FDA proposed a new format in 2000 to improve prescription drug labeling for physicians, also known as the package insert. One FDA study showed that practitioners found the labeling to be lengthy, complex, and hard to use. The proposed redesign would feature a user-friendly format and would highlight critical information more clearly. The FDA is still reviewing public comments on this proposed rule. The agency also has been working on a project called DailyMed, a computer system that will be available without cost from the National Library of Medicine next year. DailyMed will have new information added daily, and will allow health professionals to pull up drug warnings and label changes electronically.

Error tracking and public education: The FDA reviews medication error reports that come from drug manufacturers and through MedWatch, the agency’s safety information and adverse event reporting program. The agency also receives reports from the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia, or USP (see “Who Tracks Medication Errors?”).

A recent ISMP survey on medication error reporting practices showed that health professionals submit reports more often to internal reporting programs such as hospitals than to external programs such as the FDA. According to the ISMP, one reason may be health professionals’ limited knowledge about external reporting programs.

The FDA receives and reviews about 300 medication error reports each month and classifies them to determine the cause and type of error. Depending on the findings, the FDA can change the way it labels, names, or packages a drug product. In addition, once a problem is discovered, the FDA educates the public on an ongoing basis to prevent repeat errors.

In 2001, the agency released a public health advisory to hospitals, nursing homes, and other health care facilities about the hazards of mix-ups between medical gases, which are prescription drugs. In one case, a nursing home in Ohio reported four deaths after an employee mistakenly connected nitrogen to the oxygen system.

The ISMP reports medication errors through various newsletters that target health professionals in acute care, nursing, and community/ambulatory care. The ISMP also has launched a newsletter for consumers called Safe Medicine.

In December 2003, the USP released an analysis of medication errors captured in 2002 by its anonymous national reporting database, MedMARX. Of the errors reported to MedMARX, slightly more than one-third reached the patient and involved a geriatric patient. Many of these medication errors were found to be harmful.

Source

4. Preventing Medication Errors

Medication Errors: Definitions and Classification
Jeffrey K Aronson

Classification of Medication Errors

The best way to understand how medication errors happen and how to prevent them is to consider their classification, which can be contextual, modal, or psychological. Contextual classification deals with the specific time, place, medicines, and people involved. Modal classification examines the ways in which errors occur (e.g. by omission, repetition, or substitution). However, classification based on psychological theory is to be preferred, as it explains events rather than merely describing them. Its disadvantage is that it concentrates on human rather than systems sources of errors. These classifications have been discussed in detail elsewhere.

Psychologists consider an error to be a disorder of an intentional act, and they distinguish between errors in planning an act and errors in its execution. If a prior intention to reach a specified goal leads to action, and the action leads to the goal, all is well. If the plan of action contains some flaw, that is a ‘mistake’. If a plan is a good one but is badly executed, that is a failure of skill.

Figure 2:

This approach yields four broad types of medication error (numbered 1–4 in Figure 2). Mistakes can be divided into (i) knowledge-based errors and (ii) rule-based errors. Failures of skill can be divided into (iii) action-based errors (‘slips’, including technical errors) and (iv) memory-based errors (‘lapses’).

Knowledge-based errors can be related to any type of knowledge, general, specific, or expert. It is general knowledge that penicillins can cause allergic reactions; knowing that your patient is allergic to penicillin is specific knowledge; knowing that co-fluampicil contains penicillins is expert knowledge. Ignorance of any of these facts could lead to a knowledge-based error.

Rule-based errors can further be categorized as (a) the misapplication of a good rule or the failure to apply a good rule; and (b) the application of a bad rule.

An action-based error is defined as ‘the performance of an action that was not what was intended’. A slip of the pen, when a doctor intends to write diltiazem but writes diazepam, is an example. Technical errors form a subset of action-based errors. They have been defined as occurring when ‘an outcome fails to occur or the wrong outcome is produced because the execution of an action was imperfect’. An example is the addition to an infusion bottle of the wrong amount of drug.

Memory-based errors occur when something is forgotten; for example, giving penicillin, knowing the patient to be allergic, but forgetting.

5. Reporting Medication Errors

Computer based medication error reporting: insights and implications
M R Miller, J S Clark, and C U Lehmann

Of the 1010 medication errors reviewed, 298 (30%) were prescribing errors, 245 (24%) were dispensing errors, 410 (41%) were administration errors, and 57 (6%) involved medication administration records (MAR). Following expert review, 208 errors (21%) were deleted because they had been inappropriately coded as errors and 97 (10%) were added as they were not initially coded despite having occurred. In addition, 352 medication error reports needed to have the subtype of error reclassified; 207 (59%) of these involved the reporter choosing the non‐descript “other” category on the reporting tool (such as “Prescribing other”) which was able to be reclassified by expert review. The overall distribution of error type categories did not change significantly with expert review, although only MAR errors were underreported by the reporters. The most common medications were anti‐infectives (17%), pain/sedative agents (15%), nutritional agents (11%), gastrointestinal agents (8%), and cardiovascular agents (7%).