Medication errors are a common problem in pediatric outpatients, and high-alert medications such as opioid analgesics are a major cause of emergency department visits in both children and adults. This study evaluated the quality of analgesic prescriptions in patients being discharged from a pediatric teaching hospital. Most prescriptions contained at least one error, including frequent use of error-prone abbreviations and failure to use weight-based dosing, and 3% of prescriptions were judged to have the potential for serious patient harm. Computerized provider order entry (CPOE) has been advocated as a means of preventing medication errors in children, but in a prior study, CPOE actually failed to reduce dosing errors in children.