I've done adverse event review at a couple of different organizations, and one of the biggest challenges in implementing changes to prevent repeat events is the belief or desire to believe that the failure to avoid these events are due to a single, isolated error.
Current best practices for avoiding medical errors are two-tiered. The first goal is to prevent the primary error, but it's a bit ignorant to believe that those primary errors can be reliably avoided completely so the second tier is to ensure that individual errors would have to make it through a gauntlet of systemic error prevention strategies in order to make it to the patient, and this is a pretty clear case of both an individual error, as well as multiple failures to prevent or mitigate the error through systemic error prevention.
The result of viewing this is primarily an individual error is typically ineffective, we remind nurses to read the vial when removing it from the pyxis and prior to administering, the problem is that it's unlikely the nurse in question had never heard this suggestion before. This often not only the easiest (laziest) fix, there seems to be some psychological comfort for us to believe that risks to patients are simple rather than complex, so we ignore the larger problems. A systemic fix on the other hand to pulling the wrong med, which we've done at my current facility and found it effective, is to first change the predictive text to require 4 letter before any medications are shown, and we've also added decoys to the med list that results, so your med is not always the first med on the list even if you type the full name, this changes the habit from typing part of or the full name of the med and then reflexively picking the first med on the list to having to always hunt for the med. Our rate of 'wrong med' scans at the barcode scanning step has dropped from almost 2 a day to less than 2 a month. For a few years prior to this, the issue was addressed an individual error issue and should be fixed by reminding nurses to look at their meds, which had no effect on the problem. The same basic premise is true here, viewing this as primarily a problem with the actions of an individual nurse isn't likely to changing the serious systemic failure that also contributed to this patient's death.