Medication errors at the time of hospital admission are common, and some have the potential to cause harm. Better methods of ensuring an accurate medication history at the time of hospital admission are needed.

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CASE 1: A 70-year-old woman is admitted with an acute dysphagic stroke. A pureed and thickened liquid diet is started during her hospital stay. Efforts at rehabilitation are hampered by severe knee pain from chronic osteoarthritis. Her pain is initially managed with a short-acting preparation of oxycodone hydrochloride, which is then switched to an analgesicequivalent dose of the same drug in a sustained-release preparation. The next day the patient is found to be unresponsive. CASE 2: A 75-year-old man with a percutaneous endoscopic gastrostomy tube complains of severe heartburn and undergoes endoscopy. He is found to have severe reflux esophagitis and is given omeprazole, 20 mg twice daily, to be administered through the feeding tube. After 1 month of therapy the patient's symptoms have not resolved.

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