A 38-year-old woman with newly diagnosed atrial fibrillation presents to the anticoagulation clinic to initiate warfarin therapy. Vital signs are stable: BP 118/76, HR 102, RR 16, temperature 37.2°C. The patient is prescribed warfarin 5 mg daily. Before taking the first dose at home, the patient discovers the pharmacy dispensed 50 mg tablets instead of 5 mg tablets—a 10-fold overdose. The patient contacts the clinic immediately without taking any medication. INR is found to be 2.3 (therapeutic range 2-3). The hospital's quality and patient safety team initiates a comprehensive root cause analysis of this medication error. Which of the following represents the most appropriate focus for this quality improvement initiative?

1. A)Terminate the dispensing pharmacist and implement a "name and shame" protocol to prevent similar errors by other staff members
2. B)Require the patient to sign an acknowledgment form accepting liability for medication verification before future prescriptions are filled
3. C)Implement automated dose verification alerts that flag prescriptions for warfarin exceeding 10 mg daily before dispensing
4. D)Conduct a systems-level analysis to identify process failures, communication breakdowns, and latent conditions that allowed the error to reach the patientGABARITO
5. E)Increase malpractice insurance premiums and establish a financial penalty system to incentivize individual pharmacist accountability