1. The nurse administered the wrong medication to the baby. 2. The nurse who made the mistake informed other nurses beyond the glass wall about the medication error through a note, and the colleagues who confirmed it felt the seriousness of the situation and were flustered. 3. The head nurse who came in for emergency care was also informed of the medication error but did not share it with other medical staff or during the treatment process. 4. The baby's death: Without knowing the fundamental cause of the medication error, only incorrect emergency measures were taken, and ultimately, the baby passed away.