Hospitalized children are particularly vulnerable to medication errors due to the complexity of weight-based dosing and the resulting potential for calculation errors. Computerized provider order entry (CPOE) has been widely advocated as a means of preventing such errors. In this study, implementation of a CPOE system did not initially reduce adverse drug events in a pediatric intensive care unit. However, when a decision support system for calculating weight-based dosages was added to the CPOE system, medication errors declined significantly. A 2008 Sentinel Event Alert published by The Joint Commission highlighted the prevalence of pediatric medication errors and recommended potential solutions.