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Medication errors are unacceptably common. They occur during each step in the process of providing medication to hospital inpatients; prescribing, preparation, and administration. A recent UK study found a prescribing error in 1.5% of all medication orders written (a potentially serious prescribing error in 0.4%).1 Even higher error rates are associated with the administration of medication, in particular with intravenous medication. One or more errors occurred in about half of all intravenous drug preparations and administrations and 1% of doses were associated with a potentially severe outcome.2 Whereas the study by Taxis et al2 investigated a cross section of intravenous drug administrations including a large number of doses given by injection, the study by Husch et al3 focused on intravenous drugs administered via infusion pumps. Their study of 286 patients receiving infusion therapy found that almost …