In this small study we wish to highlight the difference that exists between the nationally recommended dilution of 0.01% (1 in 10 000) with the dilution used in our routine patient care 0.00125% (1 in 80 000) when preparing potassium permanganate soaks. We suggest that patient and clinician education should emphasize the importance of visual assessment rather than formulaic calculations in the safe preparation of potassium permanganate solution.