This case study illustrates an ongoing therapeutic dilemma which continues to place the patient's welfare at risk. The safety predicament is associated with the transfusion of blood or their products to the correct patient. Predictably, healthcare scholars declare that when clinical practice is ineffective, a “theory-practice gap” is typically responsible. Within this paradigm there is often a gap between theoretical knowledge and its application in clinical practice. Most of the evidence relating to the non-integration of theory and practice makes the premise that environmental factors will influence learning and practice outcomes, hence the "gap". However, it is the author's belief, that to "bridge the gap" between theory and practice an additional component called “Ethics” must be appreciated. This introduces a new concept “theory-practice-ethics gap” which must be considered when reviewing some of the unacceptable appalling outcomes in health care practice