In today's highly competitive and economic driven era, health care organizations strive for quality patient care. One of the major resources in delivering quality care in a health care organization is health care personnels. Similarly, emplaced systems are also equally important for providing the best quality care to patients and their family members. Hence, loop holes or malpractices at institutional or individual levels could endanger patients' lives. Simultaneously, it adversely impacts on health care organization’s reputation and prestige. Drug error is one of the commonest incidences that occur at a health care organization. These could be severe enough that it could endanger a patient’s life. Various factors contribute towards it, such as human (health care staff or patient), and organizational. Adverse consequences because of medication error could further increase if it involves chemotherapeutic drugs. However, near miss/ close call incidences could potentially end up into fatal incidences. However, they also serve as a great learning and improvement opportunity for preventing future reviewable sentinel incidences at health care organizations. This paper is highlighting a case scenario related to non-reviewable sentinel event in light of Reason's four stage model of human error theory, organizational and human (health care professionals and patient) factors that contributed to the event and lastly recommendations are presented in light of the reviewed literature.