Unlabeled medications on the sterile field are a known patient safety hazard. In 2006, the Joint Commission on the Accreditation of Healthcare Organizations issued a requirement under the National Patient Safety Goals mandating labeling of all medications, medication containers, and other solutions on and off the sterile field. Research at New York-Presbyterian Hospital/Weill Cornell has found, however, that labeling is not the only source of potential medication safety issues on the sterile field.