This essay offers a critical reflection on a nursing-related medication error, examining the incident where a nurse's actions led to a patient's death. It explores the nurse's negligence, lack of adherence to evidence-based practices, and failure to consult with senior nurses, highlighting violations of the ICN Code of Ethics and NSQHS standards. The essay emphasizes the importance of ethical conduct, medication safety, and adherence to NMBA guidelines to prevent similar errors and ensure patient well-being. It outlines action plans such as seeking guidance, training, and incorporating evidence-based practices to improve nursing care. The reflection uses Rolfe's model to analyze the incident, emphasizing the nurse's responsibilities, the impact of actions, and the need for improved communication and adherence to standards. The essay concludes with a call for nurses to prioritize evidence-based practice to prevent errors and ensure safe, quality patient care.