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Dr Wheeler and his colleagues (August 2004 JRSM1) make a strong case for standardized labelling to avoid confusion over ratios and percentages in drug solutions. May we draw attention to another potential source of confusion in relation to drug labelling. The unlabelled ampoule in Figure 1, which we presume to have contained Betnesol (betamethasone), was taken out of its packaging during routine cataract surgery for planned periocular injection. Theatre staff reacted appropriately by discarding it, and we reported the incident to the Medicines and Healthcare products Regulatory Agency. We also advised the manufacturers. The absence of a label was due to a manufacturing error, fortunately not coupled with the loss of coloured bands which do help to distinguish it from other products. However, this picture illustrates another potent source of error. Even when intravenous medications are correctly labelled, the similarity between their appearances is an example of a latent or potential systems failure.