The wrong vial did not scan. The technician could continue. Critical identifying information was missing. The technician could continue. A second technician handling an unfamiliar drug did not inspect the vial or images. The process continued. A supervising technician did not catch the error. A pharmacist reviewed the case in less than half a minute without bringing the physical syringes to the verification station. The wrong drug was approved. A mismatch between the number ordered and the number supplied was not reconciled. The syringes were then delivered to an operating room bearing the name of the intended anesthetic. The last point deserves special emphasis. Anesthesiologists must ordinarily be able to rely on pharmacy-prepared and pharmacy-verified sterile products. As the chief of anesthesia told surveyors, a clinician cannot work in a hospital and be unable to trust medications sent from the pharmacy. That reliance is not a defect in anesthetic practice; it is foundational to a system of professional division of labor. The defect was that the pharmacy system supplied labeled, approved syringes that did not contain what their labels said they contained. Whom is hospital trying to blame! Anesthesiologist!