Almost a century ago, the April 9, 1929, issue of the International Herald Tribune reported the death of three young brothers. All of them had been given a dose of thallium acetate 10 times what was intended, because of a decimal-point error. Decimal-point errors occur regularly. For instance, on October 7, 1998, The New York Times reported the death of a 10-month-old from a decimalpoint error. In May 2001, the Canadian Institute of Safe Medication Practice (ISMP) reported two deaths caused by decimal-point errors: In two separate cases, .5 mg of morphine was misread as 5 mg. The ISMP report mentioned that decimalpoint errors were among the first safety issues the Institute had dealt with when it was founded almost 10 years ago. We are still risking such errors every day…