The typical process for administering medications in a hospital provides great opportunity for missed handoffs and errors. On average 30 people touch a medication before it is administered. Imagine the complexity for a nurse who typically administers 10 medications per patient per day, or the safety risks for a transplant patient who might receive 36 medications in a single shift. As healthcare leaders, we must address the technology aspects of safety while promoting a culture of safety and addressing the process aspects of safe, high-quality care. Billie Waldo