Standard 1 of the NMBA Registered Nurse Standards for Practice outlines the requirement for nurses to use best available evidence for safe, quality practice and to develop practice through reflection on experiences, knowledge, actions, feelings and beliefs (NMBA, 2016). The aim of this essay is for students to describe, and reflect on, a nursing related event reported in the media and using the National Safety and Quality Health Service (NSQHS) standards developed by ACSQHC (Australian Commission for Safety and Quality in Healthcare) identify what nurses might do to improve their practice and reduce the risk of a similar error.