There's a situation in which a kid received an ototoxic drug. The doc wrote to check levels after the 3rd dose. It was never done. The doc realized it 24 hours later, re ordered it and the level was way too high. The kid is deaf.
My unit, when we get those orders will write the number of the dose on the mar (#1, #2, etc.) and when it's the 3rd dose will write that the level is due. This, in addition to verbal report. To my knowledge, we've never missed a level; our system works pretty well. What's your system?