"Staff 2 believed medications were set up correctly was influenced by the belief that the person’s medication dosage must have changed because of the way the meds were packaged.  Contributing to the staff’s belief that medication dosage changed was further influenced by the person’s 3pm medication dosage matching the 9am medication dosage.  

An additional factor that had other staff following staff 2’s lead in only giving half the med, rather than following medication protocol and ensuring that the med label and the Medication Administration Record (MAR) match the dosage in the bubble pack, is that there are a lot of policies for staff to know. In the absence of stable policies the staff likely followed the veteran staff’s actions and assumed if there was a med change the veteran staff would have known as well as followed policies.