To the Editor.
—The articles by Dr Classen et al,1 Dr Bates et al,2 and Dr Lesar et al3 are all excellent in their own right. The problem is that they appear at all. If we look back to 1995, we find an article by Leape et al4 that outlines a systems analysis of adverse drug events (ADEs). Clearly it is one thing to analyze a problem and quite another to put acceptable solutions to work.I strongly agree that quality improvement teams and simplified systems are part of the answer, yet I believe that the extreme care needed to make certain that patients understand their condition and its treatment is not being taken. Placing the financial burden at $136 billion should open some eyes, and, of course, the human toll is unconscionable. At our clinic, we now take the time to develop a printed schedule detailing when and