OBJECTIVE Complications from pleural drainage procedures are common, but their incidence is often underrecognized. Significant morbidity and mortality can arise, particularly as a result of poor procedural technique, lack of training and inadequate supervision. This review discusses safety considerations of common pleural procedures, methods for risk minimization and training issues. RESULTS Recent data have identified deaths and significant adverse events associated with pleural drainage procedures. Evidence suggests that significant risk reduction might be achieved by restricting the number of physicians authorized to perform a pleural aspiration to a smaller expert group who have had specific training and regularly perform the procedure. Pleural ultrasound has been shown to increase the accuracy of fluid localization and decrease the risk of postprocedure pneumothorax. CONCLUSIONS Strategies to improve physician training, reduce unnecessary pleural procedures and improve site selection (using pleural ultrasound) may reduce complication rates. Consequently, several international authorities have recently published updated guidelines and educational packages aimed at improving the safety of pleural intervention. Pleural ultrasound has the potential to significantly decrease adverse event rates, but requires specific training and has several possible pitfalls.