It was a night shift. You remember it perfectly, of course. You went into the patient’s room and gave the blood pressure medication, almost without thinking. Of course, you checked the five rights of drug administration. You checked it was the right medication. You had it in your hand. It was the right dose. Pharmacy just sent it up. It was the right patient… Just as the patient swallowed down the pill, you realised that the pill was meant for their roommate. You just made a med error, and all it took was skipping a step in the middle of the night when you were tired.