Drug administration is one of the highest risk areas of nursing practice and a matter of considerable concern for both managers and practitioners. The aim of this study, carried out in a district general hospital, was to identify any common themes that underlie the occurrence and reporting of drug administration errors. Data were collected from a variety of sources: drug error reports, questionnaires to nurses and nurse managers, and interviews with nurses who had been involved in drug errors. Several areas of particular concern emerged, including: the nurses' confusion regarding the definition of drug errors and the appropriate actions to take when they occurred; their fear of disciplinary action; their loss of clinical confidence; the variation in managerial response; and a possible lack of nurses' mathematical skills. The results from the study demonstrated that it was likely that many drug errors were not reported, for a variety of reasons. It is recommended that all of these issues are addressed as a matter of urgency, for the sake of both patients and nurse practitioners.