The care process for patients with cancer is particularly complex and affected by multiple factors that can impact patient safety. A detailed analysis of the entire care process allowed the author’s institution to identify critical points that affect patient safety and to implement safer practices. The treatment of patients with cancer is unique in that it requires numerous, successive, and interrelated interventions by different healthcare professionals (pharmacists, doctors, nurses, nursing assistants). These clinicians are responsible for the administration of antineoplastic chemotherapy, which requires special handling. These drugs (a) have a narrow therapeutic range, (b) are administered in varying doses, (c) are administered in protocols that combine multiple agents, (d) have doses and numbers of cycles that are variable, and (e) are often high in cost. The risk of high-severity medical errors is great with these agents, and adverse effects from errors are disproportionate to those from other drugs.