I am the principal investigator on a study funded by the Agency for Healthcare Research and Quality: Impact of a Community Hospital Computerized Provider Order Entry (CPOE) System on Adverse Drug Event (ADE) Outcomes. It addresses how CPOE can better assist nurses, physicians, pharmacists, and unit clerks in creating safer environments for medication administration. Most of our baseline data have been collected, and three things are already quite clear: medication safety is a systems problem; it involves all health care disciplines; and the intensity and level of acuity of practice environments mandate that we address the first two issues.

Although I appreciate Thomas Meyer's emphasis on impressing upon future nurse clinicians the importance of rigor and accuracy in all aspects of medication administration, I am concerned with his message of "there is no permissible level of error." All humans make mistakes. It's how we perceive, examine, and manage these errors that determines our ability to prevent them. I wonder how often future nurses will receive only a point of view of individual blame in their education. Just how effective are nurses in sharing strategies for dealing with unsafe systems? Novice nurses need to know that health care systems are not sacred and that they can be broken. It's not only okay-but imperative-to say this. We need to give future clinicians the strategies that can help them succeed in their practice and, in turn, help us build safer environments.

Rita Snyder, PhD, RN, CNAA, BC

Tucson, AZ