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Patient safety and optimisation of worker performance are high current priorities. Arguments over employee drug testing have been debated over the past two decades.To review prior information to reveal how current principles and practices regarding pre-employment drug testing of health care workers evolved, and to explore pressing current and future issues.A literature search of Medline from 1980 to 1999 was performed. This yielded seven citations that reported results of pre-employment drug testing of health care workers, which we critically reviewed.The process by which a rational testing process was developed for pre-employment urine drug screening in the health care field is illustrated. Also depicted are some important principles, inequities, and shortcomings of the system. The range of positive tests was wide, from 0.25% to 12%. Testing was not always applied uniformly to all health care workers. It became apparent that positive tests also require medical review to determine if they were truly due to illicit substance use.Although pre-employment drug testing programmes in the health care industry have been firmly in place for many years, it is unclear whether such strategies have achieved their stated purposes. The next step is to study whether such programmes are effective at accomplishing specific goals, such as decreasing absenteeism, turnover, accidents, and medical errors, in order to justify continuing pre-employment testing versus changing to an alternative testing strategy.