This study found a remarkably high incidence of medication errors—nearly two errors per patient—in skilled nursing facilities. Interviews with staff revealed several underlying factors: polypharmacy, overworked staff, poor communication between nursing home staff and physicians, lack of a culture of safety, and lack of reliable systems for medication ordering and administration. Recognition of the high potential for medication errors in nursing facilities has led to the development of toolkits for improving medication safety. A serious medication administration error at a nursing facility is discussed in this AHRQ WebM&M case commentary.