A nurse receives a verbal order which was understood to be for avert 6. the physician actually ordered antivert 25 mg daily. the patient is also taking prozac®/sarafem® (fluoxetine), which when taken with avert can be life threatening. the patient's condition stabilizes and an interdisciplinary team meets to perform a root cause analysis hoping to learn from the mistake. the nurse was part of the group formed to help identify ways the system could be changed to prevent similar errors. this situation describes: