A resident’s MAR indicates that blood pressure should be che…

A resident’s MAR indicates that blood pressure should be checked and documented before administration of a blood pressure medication. It also indicates the medication should be held if the resident’s systolic blood pressure is below 120. An MA forgets to check blood pressure and administers the drug. The resident’s blood pressure drops dangerously low afterwards and the resident loses consciousness. Which of the following causes of medication errors is involved most directly in this case?