The Code of professional conduct and ethics guide the nurses in their day-to-day practice to understand their professional responsibilities in caring for patients in a safe, ethical and effective way (ABA 2000). Although many types of errors can occur in the healthcare setting, according to medical protection Ireland most of the medication errors can be avoided by simple checking procedures and clear, open communication( Sorrell 2017). Several ethical issues may arise as a result of medication errors such as harm to patients, whether to disclose the error, erosion of trust, and impact on quality care (Sorrell 2017). Patient 's has all the freedom to decide what should or should not happen and to gather information before undergoing a test/procedure/surgery. The healthcare staff can only act as a facilitator in patient 's decision making. With regard to this case study, I felt that all the above points should be addressed in Suzan’s clinical management. Reflective practice is undoubtedly an important concept in nursing to think about to reduce the possibility of errors in the future practice. The day that Ms. Suzan received the double dose of Omniplaque drink, I went back through the chart and realized that this medication could do more harm to her kidney as well as liver. So I contacted the doctor immediately to do the needful at the earliest for Ms. Suzan to avoid further damage. Medical errors are not typically caused by a negligent or incompetent health care