The human factors of medication safety: Wings fall off

The paper The human factors of medication safety: Wings fall off by Peter Hambly was published in the online version of the Journal of Patient Safety and Risk Management on 11 December 2025.

Hambly argues that intravenous medication safety in acute hospitals is a critical but overlooked problem — estimated at one serious error per 133 anaesthetics — and that relying on vigilance alone is ineffective. He advocates standardisation, automation through ready-to-administer products, and systemic redesign rather than individual blame.