Yes, the doctor and pharmacist and administering nurse failed here. But that is not useful. The useful bit is why they failed, and that seems to be a mix of "busy" with "software sucks".

The doctor didn't order 38.5 tablets -- at least she didn't think she was. She thought she was ordering a dose per kg, not a quantity of tablets.

You say the screen is very clear. It's clear enough when I read it. I had a good night's sleep and I am alert and awake. I've been primed by the article to look for the error. I imagine I would easily miss the mistake if I've been working hospital wards for the last 10 hours on a rolling nightshift, looking after some very ill patients.

The fact that it's possible to use two entirely different dosing systems to order medication and have the screen not clearly indicate[1] which is being used is so obviously sub-optimal I'm kind of surprised to see anyone saying that it's "just pilot error".