TABLE 3. Examples of MRE Report Summaries and Codes.

Summary	Code
	Category	MMP	Type	CF	Outcome (severity)
Physician entered medication orders in the wrong patient's record. The error was identified and orders discontinued prior to reaching the patient.	Wrong orders	Ordering	Med error	Provider	None (none)
Ordered dose units did not match dose units that were dispensed by the pharmacy (prescribed in mEq but dispensed in mL). The printed medication label did not identify the dose in both units for verification with the physician's order.	Labeling error	Dispensing	MREa	Task/process, technology	None (none)
Medications were not available in the automated dispensing machine at the scheduled administration time. Medication administration delayed while nurse notified pharmacist and waited for delivery.	Not available	Stocking	MREa	Task/process	Delay of therapy (unknown)
Patient inadvertently occluded IV tubing during repositioning. Interruption in medication delivery led to a drop in blood pressure.	Delivery route disrupted	Administering	MREa	Patient	Hemo-dynamic instability (moderate)
Patient was given a benzodiazepine to reduce anxiety related to respiratory difficulties following beta-blocker administration. Patient then became bronchospastic with stridor and panicky thoughts of death. Team attempted to calm patient and treat with a bronchodilator, however patient continued to decompensate. Sedation, intubation, and IV fluids were required to stabilize.	Unexpected response to therapy	Monitoring	ADE	Patient	ADR (severe)

Note. ADR = adverse drug reaction; CF = contributory factor; MMP = medication management phase.

^aA MRE that was neither a medication error nor an ADE.