Interestingly, from an RN I know, this type of thing in the old days would have been caught by a two party check system. One person draws the drug, the other ch

Interestingly, from an RN I know, this type of thing in the old days would have been caught by a two party check system. One person draws the drug, the other checks the intended treatment and the prepared drug. Then again, holy crap, if they've normalized deviance to the point people are flying through overrides unconsciously, let alone 5 that's either one horrible UX, totally dysfunctional workload management is at play, or process has fundamentally failed somewhere. I'd be surprised if actual mens rea was in play, but I'd have to read up more on the details of the case. Though I do know that pharmacists actually have a quixotic way of mixing CaPs in drug names in order to visually differentiate homoglyphic drug names to decrease the odds of mistaking one drug with another. So it isn't completely out there.