"The less-than-perfect medication system": a systems approach to improvement.

The 1999 Institute of Medicine (IOM) report increased the focus by health care providers, regulators, and the public on the cause and effect of medical errors. The IOM report recognizes the complexity of the problem of medical errors and advocates a systematic approach to error reduction. Medication delivery systems in health care facilities are an excellent example of the complexity that exists. General Systems Theory (GST) provides a framework to evaluate system design and effectiveness. This article presents an example of the use of GST in the design and evaluation of medication systems with a focus on error reduction.