Adverse drug event surveillance is an important strategy to both identify and prevent medication errors, particularly for high-risk medications. This study reports on the development of a real-time surveillance dashboard to enable pharmacy review of high-alert medication orders and complement a system already using computerized provider order entry and clinical decision support. Of nearly 30,000 hospitalizations studied, there were more than 2200 that involved exposure to warfarin, 8300 to heparin or enoxaparin, and 890 to aminoglycosides. Real-time pharmacy review of the dashboard provided a vehicle to prevent medication errors or optimize therapy; for example, 55% of patients receiving aminoglycosides did not have a baseline creatinine. The authors argue that even sophisticated computerized systems require active surveillance systems to leverage technology and provide necessary medication safety.