The results of a small-scale observational study and a root cause analysis were used to describe the types of errors that occur in medication administration to patients with dysphagia and identify possible solutions. Patients with dysphagia in four UK hospitals were shown to be three times more likely to experience medication administration errors than patients without dysphagia and, as a consequence, were at increased risk of harm. Regular observation of nurses administering medicines to patients with dysphagia is a simple intervention that would enable individual practice to be reviewed. It would also allow system, practitioner and patient factors that underpin any ‘near misses’ to be addressed to enhance the quality of patient care.