The main aim of our work was to improve the safety of opioid use in our institution, an acute general hospital with 620 beds. Initially, all reported opioid errors from 2001 – 2006 were audited. The findings directed a range of multidisciplinary staff educational inputs to improve opioid prescribing and administration practice, and encourage drug error reporting. 448 drug errors were reported, of which 54(12%) involved opioids; of these, 43(79%) involved codeine, morphine or oxycodone. 31 of the errors (57%) were associated with administration, followed by 12(22%) with dispensing and 11(20%) with prescribing. There were 2 reports of definite patient harm. A subsequent audit examined a 17-month period following the introduction of the above teaching: 17 errors were noted, of which 14(83%) involved codeine, morphine or oxycodone. Again, drug administration was most error-prone, comprising 11(65%) of reports. However, just 2(12%) of the reported errors now involved prescribing, which was a reduction.