T HE Canadian Standards Association (CSA) Symposium on Ergononics in Drug Delivery was held on January 21, 1997, at The Michener Institute for Applied Health Sciences in Toronto, Canada. Ergonomics is the engin'eering discipline that reconciles the design of products and systems with human capabilities and linfitations. Inattention to human factors can lead to a misfit between the task, the physical environment, and the people. The impact of human factors is only beginning to be appreciated in the design of medical systems. Therefore, it is not surprising that human error is a major contributing factor to many mishaps in medicine. Human factors contribute to errors during anaesthesia, particularly those associated with the administration of drugs. Drug error is increasingly being recognized as a major cause of morbidity and mortality in patients undergoing anaesthesia and misidentification of ampoules or syringes is often a contributing factor. In the last year, the CSA has received numerous requests from concerned individuals to address several pressing issues in drug delivery. Most importantly, it was suggested that the CSA develop national standards for the labeling of drug ampoules and vials. In addition, the need for a national standard for Metered Dose Inhaler Spacer Devices was identified. In order to develop an effective standard, it is important that all affected groups be given an opportunity to provide their perspective. Therefore, the purpose of the symposium was not only to educate those who attended, but to determine if new standards are required. The symposium was attended by individuals representing academia, consumer groups, pharmaceutical and device manufacturers, health care practitioners, and hospital and retail pharmacists. In addition, representatives from both the provincial and federal regulatory authorities attended. The sessions were moderated by Dr. Wayne Taylor, an Associate Professor of Business, Public and Health Policy at McMaster University. The morning discussion was devoted to ergonomic issues in drug delivery, drug safety in critical care environments, and the design of a blueprint for error-proofing pharmaceutical trademarks and labels. Perspectives were provided by the Canadian Anaesthetists' Society, the Canadian Drug Manufacturers Association, the Canadian Nurses Association, Health Canada Drugs Directorate, and other interested organizations. The discussion generated four specific recommendations.