PURPOSE OF REVIEW: Long-term video-electroencephalography monitoring (LTM) in epilepsy monitoring units (EMUs) exposes patients to a variety of serious adverse events (SAEs) and safety issues, which have recently caught attention and are summarized in this review. RECENT FINDINGS: SAEs observed during LTM affect about 10% of patients and include secondary generalized tonic-clonic seizures, seizure clusters and status epilepticus, unusual for the patient; seizure-related falls, injuries, fractures, and aspiration; postictal psychosis; and cardiorespiratory distress, including sudden unexpected death in epilepsy (SUDEP) and near-SUDEP, which were encountered by more than 10% of European and Australian EMUs. Accordingly, 3% of US-based EMUs suffer a death within a 1-year duration census. Many of these SAEs might be promoted by antiepileptic drugs (AEDs) withdrawal, for which no specific guideline is currently available. Current recommendations regarding optimal organization of EMUs, and in particular continuous supervision by a dedicated staff, are not followed by respectively 20 and 26% of European and US-based EMUs. SUMMARY: SAEs during LTM are a significant concern and might be aggravated by suboptimal EMU organization and staff education. Lack of high-level evidence stands out as the main limiting factor to the development and dissemination of appropriate guidelines.