Solid oral Methotrexate (Methotrexate in tablet form) has been used for many years as an effective measure to treat severe rheumatoid arthritis and severe psoriasis. When taken at the right frequency and dose Methotrexate is a safe medication. However, in the community in the UK between 1993 and 2000, Methotrexate has been implicated in the deaths of some 25 patients and a further 26 cases of serious harm which have required hospitalisation [1,2]. In 2003 the National Patient Safety Agency (NPSA) began a programme of work to investigate the causes of errors with Methotrexate and to develop and implement solutions in response. Since then, three projects have been undertaken: The development of a new patient treatment diary; An investigation of IT systems in GP's surgeries and community pharmacies; and An assessment of the packaging and labelling of Methotrexate with patients and healthcare practitioners and the identification of changes which should improve patient safety. This paper describes the research and results from the third project.