This report presents a case study focusing on an adverse event involving a 7-year-old boy in an emergency department who experienced a medication error. The report details the patient's presentation, principal diagnosis (Colles fracture), and the adverse event, which involved the administration of an incorrect dosage of ketamine. It describes how the event was managed by nursing and medical staff, including the immediate response to the patient's respiratory depression. The report analyzes the current workplace system, referencing the National Safety and Quality Health Service Standards by the Australian Commission on Safety and Quality in Health Care, and compares these systems to best practice guidelines. It identifies areas for improvement in the management of adverse events, emphasizing the need for preventive measures such as proper dosage verification and the implementation of medication safety protocols. The conclusion offers recommendations regarding changes required in clinical practice to minimize the occurrence of similar incidents.