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Rational drug usage, clinical regulations and pharmaceutical care are important features of health practice. Thus; we have aimed case report to elaborate the clinical pharmaceutical services. A 3 year old girl, was presented in a hospital with minor burn that happened by spilt hot water on her wrist. She was in severe pain. The emergency ward staff applied an ointment. The doctor instructed injection Dormicum two times with short gape and then 3rd injection of Pavulon (Pancuronium). Patient went silent and started losing consciousness and eventually passed away. In view of the above facts and circumstances the inquiry board and judiciary took action against the negligence, mishandling. While; going through the investigation the inquiry board did not bothered the channel through which this injection came without proper check that is therapeutical drug monitoring, prescription reviewing, bio-safety and pharmaceutical evaluation. Furthermore, it is not a single death but representation of so many casualties because of the wrong medications. The medial practice needs some more legal, professional and principled restrictions to make sure the safe and correct therapy plans. The clinical legislation, drug rules and medical practice seriously need the attention of judiciary, society and leadership to assure the safety of precious live.       Key words: Wrong medication, medical malpractice, professional negligence, pharmaceutical services, Suo-moto notice of chief justice of high court.

Avoidable childhood death: A case of mismanagement and inappropriate medication use