MEDICATION ERRORS STILL occur in the perianesthesia setting as in all clinical settings. One nurse accidentally administered a potassium minibag via an epidural catheter by connecting to a Y port. The patient received the whole dose before the nurse later realized she had connected the infusion to the epidural tubing. Fortunately the patient had no symptoms. This case helps to illustrate the multifactoral causes present in most medication errors. In this case standard procedures were not followed. Typically PACU nurses attached special epidural tubing with no access ports. However, the patient was recovered in the ICU and then sent to a medical floor with a capped epidural line. This led to the second cause of the problem: faulty procedure and tubing. This unit had never received a patient who did not already have special tubing, so when the patient complained of pain the nurses restarted the epidural analgesia using regular IV tubing. The third issue was that a policy to double check IV potassium infusions was unknown. The hospital had recently implemented a new policy that required two nurses to check pump settings and trace tubing to the site of injection. However, the nurses believed that the new policy only required two nurses to double check the medication label and dose against the medication administration record.