Since patient safety is multidimensional and grounded in ethical and legal imperatives, both ethical and legal challenges should be taken into account. In this regard, a falling incident case of a 12-day-old newborn was raised in the monthly ethics round in the Children's Medical Center of Tehran University of Medical Sciences, Iran, and the ethical and legal dimensions of patient safety were discussed by experts in various fields. This report presents different aspects of patient safety in terms of root cause analysis (RCA) and risk management, the role of human resources, the role of professionalism, the necessity of informing the parents (disclosure of medical errors), and forensic medicine with focus on ethical aspects.