Estimates of 100000 Americans dying of ‘medication errors’ each year have caught the popular imagination … and they might even be true. Psychologists regard errors as defects in intentional acts. They distinguish between ‘mistakes’—errors in planning the act, and ‘slips of action’ or ‘lapses of memory’—errors in executing the act. Both sorts of error are important in prescribing and giving medicines. Can we do anything to make the process of prescribing and giving medicines safer? We undoubtedly can, and the changes that are needed start with the manufacturer and end with the patient. Drugs can be designed to be safe and easily distinguished one from another. The prescribing environment can be made safer by ensuring that difficult work (printing drug names, checking for interactions, avoiding major dosage errors) is done by computer. We should also recruit patients to help us to treat them safely. Others have designed safety into their systems, and we should seek to do the same for prescribing and giving medicines.
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