"Medication errors are the most common of all medical errors and pose a tremendous emotional and physical cost to patients and economic burden to our health system. The most reliable estimates of medication error in anesthesia place the rate at 1-2 in every 10 administrations, or 1 in every anesthetic. Most of the errors are harmless but other wreak devastation. These errors are a failure to plan well, or to carry out a well-designed plan; less talked about but perhaps more important are routine violations of best practices. Errors arise through fast and slow thinking; violations arise from a myriad of causes. There is an extensive body of expert consensus on how to improve medication safety, starting with an institutional commitment to improving medication safety, and ending with an individual practitioner committing to doing the right thing every time. Technical solutions, pharmacy solutions, standardization, and a safety culture are major themes in medication safety. Despite knowledge of what would make us safer, economic costs, a perceived lack of urgency, human resistance to change all conspire to medication safety difficult to achieve. Low-income countries face particular challenges in medication safety. Despite these challenges, we must dedicate ourselves anew to this goal - our patients deserve no less"--