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Consider this example of an adverse event:

A woman in labour needs to receive an infusion of a particular drug to manage severe hypertension. An error occurs and she receives an incorrect dose of the drug. What are the potential causes of this situation?

Potential causes of our example drug error
Prescription error	Wrong drug prescribed
Preparation error	Correct drug prescribed but misread
Preparation error	Contents mislabelled during manufacture
Drawing up error	Incorrect drug selected
Administration error	Patient ID mix‐up, drug given to wrong patient

Q. What one thing links all of these errors?

A. The humans involved – these are all examples of human errors.

Humans make mistakes. No amount of checks and procedures will mitigate this fact. In fact the only way to completely remove human error is to remove all the humans involved. It is vital therefore that we look to work in a way that, wherever possible, minimises the occurrence of mistakes and ensures that when they do occur the method minimises the chance of the error resulting in an adverse event.