The Institute of Medicine's report,To Err is Human determined that many errors in modern healthcare can be attributed to either poorly designed or faulty systems. This website will attempt to integrate some of the concepts of systems engineering into the practice of pharmacy. This will include an introduction to root cause analysis and other tools, such as Failure Mode and Effects Analysis (FMEA) and Fault Tree Analysis which are currently used in safety engineering and have a use in medication safety initiatives.

Engineering techniques can be used to do more than detect and reduce error. While many practitioners do not want to admit it, the practice of pharmacy can be divided into a cognitive and a distributive component. The latter component lends itself well to practices designed to optimize performance and minimize error. In this case, we are referring simply to dispensing errors.

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