Healthcare organizations strive to provide safe, quality care in every patient setting. The complexities of the healthcare environment however, allows prospective errors. Medication related errors are the most common type of error and also account for a sizable increase in healthcare costs (IOM, 2000). Medication errors account for lost wages, disability, and productivity, and are responsible for over 7000 deaths annually (IOM, 2000). The Joint Commission mandates healthcare systems demonstrate strong leadership which creates a fair and just culture of safety. This approach holds both the organization and individual accountable for safe, quality patient care (Joint Commission, 2017). This accrediting body recognizes that individuals human and capable of mistakes in an often flawed system. This case study examines the human factor in a fatal medication error using a root cause analysis.