Medication errors commonly occur in many health care settings. This review of medication errors illustrates that complex, fast-paced care delivered in PACUs often occurs in an environment where patients encounter numerous processes as they move from preadmission, to preop holding, to the operating room, to PACU, and then back to a clinical unit or discharge. Using a nationally recognized framework, 645 PACU medication error records were analyzed. The errors resulted in a higher than expected threshold of harm (6.8%), with most errors occurring during the administration phase (59%) of the medication use process. Nearly one quarter of the errors involved an improper dose of a medication. Three quarters of the errors were influenced by distractions. More than 130 different products were present in the sample of cases reviewed. Problem areas identified involved epidural analgesia, patient-controlled analgesia, and duplicate doses.