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Adverse drug reactions are the fifth most frequent cause of deaths in developed countries, effectively a global epidemic. However, progress in ameliorating the problem has been slow. Pharmacovigilance currently operates without clear objectives in relation to individual decisions, with no protocol (although risk management plans are a great step forward), with obscure materials and methods used for making decisions, with very limited reasoning and discussion, and little or no follow up and audit of the results. Problems include under-reporting, poor quality reports, underuse of the latest communications technology and suboptimal individual feedback to reporters. Assessment of causality is poor, impeding decision-making. After signal detection, more active measures to assess the risk to public health are needed. Other essential factors include precision about the ways in which data are prepared and transformed into databases, the recognition of secondary effects, which may be more obvious than the primary effect, but not so easy to link causally, and cognisance of all kinds of interactions. Areas that should be developed include pharmacoepidemiology, knowledge finding (through data mining), and communication and systems technology. The general way forward seems clear: a rigorous way of documenting all the steps, from getting reports of harms into regulatory databases to assessing their effects on public health, is essential and should be publicly reviewed for weaknesses. In turn, matters would be much improved by input on benefit/harm perceptions from patient groups, influencing decisions about what should be the true targets for regulatory and pharmacovigilance activities, avoiding second guessing by regulators.