A medicine error is failure in the treatment practice that can cause actual or potential harm to the patient (Cheragi et al., 2013; Khan & Tidman, 2022). The medication administration errors can affect patients in form of adverse drug event, increase length of stay, morbidity and mortality and hospital cost of the patient (Kang, Kim & Lee, 2014; Naeem & Coronato, 2022). The sentinel high alert medication event is correlated with patient harm, and it can cause severe risk on misusing that can cause serious injury or death (Cohen, 1999; Naeem & Coronato, 2022). A sentinel error is unacceptable event in healthcare system that causes serious physical, psychological injury or death of the patient that is not related to natural progression of client disease (Neriman, 2018). The medication administration blunder can occur through failures in not following the rights of patient safety medication e.g. right patient, time, medication, dose and route of administration (Kim & Bates, 2013; Naeem & Coronato, 2022). This medication mistake may be result of individual mistake or gap in the knowledge or practice. There are many reasons in this incident that cause error in medication administration. Initially, the cause of early medication error arises because of returning of anesthesia medicine from operation room to Labor-Room. The OR staff shows irresponsibility of sending operation medicine from OR to Labor Room ward, which create serious event in the unit. The patient handing over and receiving record was missing before and after shifting for surgery. Moreover, the inadequate supervision environment leads to medication error when undergraduate nurse did not get adequate supervision from her senior nurse. As, nursing students need proper supervision and role modeling to inspire them self for performing of client medication in safe routine (Khan & Tidman, 2022). The occurring of this event is also lack of application of knowledge, skills, inappropriate supervision, competency and absence of role model during clinical shift that cause medication error. Mainly, the medication administration error occurred due to over burden of the patient in the unit. Such as, the ward was full with the patients there were only one register nurse that was accompanied with novice nurse on emergency day. So, due to emergency and overflow of the patient the RN were unable to supervise novice nursing student during her duty. Furthermore, there was lack of supervision for nursing student because the nursing student was new and she needs proper supervision for her learning from their teachers. Unfortunately, RN sends her alone to administer medication to the patient without proper supervision. Subsequently, the cause of this medication error could be lack of pharmacological knowledge to the student. Therefore, she did not apply her pharmacological knowledge in patient drug administration. She injects the injection without knowing affect and side effect of medication that leads to patient life harm. The student nurse did not perceive risk of medication, so she administers the drug to the client without knowing it effect on patient health. Furthermore, both injections were looking similar in packing that make big mistake in understanding of drug. Finally, there were lack of communication between doctor, register nurse and nursing student that cause a big medication error in the hospitals.
