You are correct. Robert Wachter has written a lot on this (see his The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age) and it's a c

You are correct. Robert Wachter has written a lot on this (see his The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age) and it's a common error to simply blame someone like a nurse for administering the incorrect medicine as opposed to seeing how that situation came to be. Healthcare has a lot to learn from how similar things are investigated in the aviation industry (note: that doesn't mean nurses get absolved of everything, just that even apparently insanely stupid mistakes are often the result of swiss-cheese style errors).