Medication errors are a significant public health issue. Their frequency and severity are currently under increased scrutiny from many perspectives. In 1996, the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) was established to promote the reporting, understanding, and prevention of medication errors. NCCMERP has published prescription writing recommendations to remedy error-prone aspects of prescription writing. An example of a hazardously written medication order and its possible toxicity is provided.