
With deeper analysis, we can see that Vaught was not careless. She was faced with obstacles that hampered her decision-making:
• Covering for a fellow nurse on break, Vaught faced an extra taxing workload.
• Vaught had limited time to acquire and administer the correct medicine.
• A new digital storing system frequently encountered errors, which made overrides common-practice staff members.
Vaught did make mistakes, but the poor human factors failed to catch those errors.