[salawat]

I also have an RN relative who described the old school processes to control for this sort of error in the old days, and the pharmacists I know have explained that even for them, they have notational conventions whereby ssimilarly spelled drugs get unique capitalizations in digital systems to visually distinguish one long arse name from another.

Also, it seems like a really bad idea to me to mix trade and chemical name in that type of system. You should search one and only one type of name at a time, simply to ensure namespace tripups like this don't happen.

This sounds like cognitive load failure from workload mismanagement.