The same problems could cause lethal over/under-doses with much more reasonable numbers of pills, i.e. accidentally ordering 2 pills instead of 1. The fact tha

The same problems could cause lethal over/under-doses with much more reasonable numbers of pills, i.e. accidentally ordering 2 pills instead of 1. The fact that 38 pills were ordered shows how crazy the problems can get, but a crazy number of pills like that should also be pretty trivial for a nurse to catch. How do you pour 38 pills down an 85-pound child's throat without considering that the consequence may be death?