Medication errors are preventable events that can negatively impact patient outcomes and result in unnecessary admissions, prolonged hospital stays, and death. Health care professionals (HCPs) often analyze these events to identify the cause of the error, determine actual or potential impact on patients, and work collaboratively to implement corrective action plans to prevent similar recurrences. This case study follows a patient through a series of hospital admissions to highlight various aspects of medication error discovery, investigation, and analysis. As they work through the case study, students categorize medication errors, identify factors leading to medication errors, explore a root cause analysis of the events, and discuss feasible solutions to prevent future errors. Additionally, students participate in discussions about “just culture” and medication error reporting, and why including reports of events that did not cause patient harm is important in improving the medication system. This case study is designed for HCPs, students in designated HCP training programs, and public health stewards.