The Institute of Medicine elevated concerns about the future of Emergency Care in a well publicized 2006 report. Continued concerns about overcrowding, increased utilization, and delays in treatment time all pose significant risks that threaten patient safety. Medication errors in emergency departments (EDs) are a particular focus of prevention strategies as past studies have outlined the problem. This study surveyed ED nurses to understand barriers to implementing National Patient Safety Goals (NPSGs) around medication safety. While the study’s response rate was poor, the authors found that several factors, including complex work environments and mixed-shift hours, are associated with reduced adherence to desired NPSGs. The authors discuss the implications of their findings and advocate for a zero-tolerance policy around preventable medication errors.