Marr et al. [1] describe the accidental administration of thiopental instead of co-amoxiclav, necessitating a caesarean section. They suggest that the error occurred due to a recent change in practice whereby antibiotic prophylaxis for caesarean section is administered pre-incision as opposed to post-delivery, and question whether they have been too hasty to change their practice.

However, the timing of the administration of antibiotics is irrelevant to the drug error that they describe. The real question that the authors should be asking therefore is not “have we been too hasty in changing our practice?” but rather “how can we minimise human error during drug administration?” They describe how they have introduced further measures to prevent a recurrence of such an event. However, it is important to realise that in any process that involves people, human error can occur. We can thus minimise, but never eliminate, the potential for human error.


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