Medication errors are a significant public health issue. Their frequen
cy and severity are currently under increased scrutiny from many persp
ectives. In 1996, the National Coordinating Council for Medication Err
or Reporting and Prevention (NCCMERP) was established to promote the r
eporting, understanding, and prevention of medication errors. NCCMERP
has published prescription writing recommendations to remedy error-pro
ne aspects of prescription writing. An example of a hazardously writte
n medication order and its possible toxicity is provided.