I can understand that an error can happen initially: as you so well know, sometimes a nurse is interrupted while entering orders.
Last time I was entering orders gradually decreasing lamictal while introducing depakote and then gradually increasing the depakote, I was interrupted 5 times. Three of these interruptions resulted in me having to leave the desk. It took soooo long to complete this order set because of the checking and rechecking.
So I get that there can be a data entry error. There really needs to be safeguards in place for this. And in your case, this sounds as if this has obviously failed. My facility has a management meeting every morning in which the DON, ADON and various department heads go over charting, faxes, MD communications, etc. They write up a report and send it back to the floor nurse for corrections/family notifications and follow up. Yay! I wonder if it takes longer to write the report than to just fix the issues?
I wish that we floor nurses had a desk away from the melee (can't remember the proper clinical name for the group of people we serve and work with) so we aren't interrupted so much. Med passes are crazy with interruptions as well. Any Tom, Dick or Harry (familymember/phone call/page/PT-OT/Environmental/PlantManagement) can interrupt this process. Ugh!