The provided case study review illustrates a blatant disregard of standard procedures and guidelines for medical practice and drug administration. The analysis uses HFACS to identify perceptual error, exceptional error, skilled-based error, decision-based error, and exceptional error as contributing factors. It also emphasizes the importance of clear communication, effective team working, accurate labeling, and proper checking mechanisms to prevent such errors. The assignment concludes by highlighting the need for patient involvement in their care and proposing solutions to reduce medical errors using HFACS.