Data continue to show that medication errors are frequent and that adverse drug events, or injuries due to drugs, occur more often than necessary.1^–4 In fact, the frequency and consequences of iatrogenic injuries seems to dwarf the frequency of other types of injuries that have received more public attention, such as aeroplane and automobile crashes.2 A recent meta-analysis reported an overall incidence of 6.7% for serious adverse drug reactions (a term that excludes events associated with errors) in hospitals.4 Between 28% and 56% of adverse drug events are preventable. 3 5^–7

Though the reasons this issue has received so little attention are complex, the reasons that medical injuries occur with some frequency are perhaps less so; medicine is more or less a cottage industry, with little standardisation and relatively few safeguards in comparison to, say, manufacturing. In fact, most of the systems in place in medicine were never formally designed, and this holds for the entire process of giving drugs.

Take, for example, the allergy detection process used in our hospital several years ago, which was similar to that used in most hospitals at the time. Physicians, medical students, and nurses all asked patients what their allergies were. This information was recorded at several sites in …