Medication management is a complex, multifaceted operation involving multiple people and numerous steps. Table 1 describes the various steps in a typical medical management process, the estimated error rate for each step, and the ‘true’ error rate based on the likelihood that the error will be intercepted [10–12]. Since medication administration is the last step in the process, the intercept rate is understandably very low. The last column in Table 1 lists the IT systems that target each step in the process. Many institutions are now implementing a ‘closed-loop’ system, i.e. end-to-end electronic medication management with seamless flow of information along the process.