While most current research has focused on preventing adverse drug events in the inpatient setting, medication errors are also an increasing cause of emergency department and ambulatory care visits, particularly among elderly patients. This examination of death certificates found a striking increase in fatal medication errors among ambulatory care patients, particularly when prescription medications were combined with alcohol or street drugs. Similar findings were noted in a prior study that analyzed deaths between 1983 and 1993. Issues of safe prescribing in the outpatient arena are discussed in a recent commentary.