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This was really silly, the reason these sizes exist and are carried is because there is a need/indication for that strength for a certain patient population and indication. I’m sure they ended up having to “walk that decision back.”

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http://www.ph2dot1.com/2008/02/color-coding-is-this-good-idea.html

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So if people need to be careful, but we (as a human race) have a track record of often NOT being careful, what do you do?

Get all people out of the healthcare system (not likely)?

Proactively fire those who are not careful?

Fire those who are likely to not be careful in the future?

Can you see the futility in the “people should be careful” argument? We are NOT careful. We have to protect patients through systems and engineering. Not hope.

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Using the term “idiot proofing” is insulting. The people who make these errors are often good people who make a mistake.

Are you, anonymous commenter, a superhuman who never has a distracted moment or never makes an error under stressful conditions?

That’s why we need “error-proofing” not “idiot proofing” or “dummy proofing.”

This isn’t about making excuses, it’s about doing what’s most effective.

The healthcare industry has preached “be careful” for decades. We see how well that’s working.

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Yes, the solution should *never* be to excercise personal responsibility. After all, if we can have somebody else take the blame for our every mistake, why in the world would we bother to be careful about anything?

How horrible that the manufacturer didn’t consider every single, obscure way to idiot-proof their product from people who don’t think they should have to be careful!

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“But last month, in the wake of the Indiana deaths, Baxter began repackaging heparin to make the different doses more distinct, including adding a large “red alert” symbol on the more concentrated dose.

Even with the change, many hospitals are still working through the last of the old vials — and in some cases have not yet received the new ones. A source close to the matter, who spoke on the condition of anonymity, told The Times on Wednesday that Cedars-Sinai was still using the old vials.”

The Baxter spokesperson said:

“Last month, the company altered the label on its dose with a concentration of 10,000 units per milliliter, changing the background color from blue to black, increasing the font size by 20% and adding a large “red alert” symbol on the vial, Gardiner said. Such changes, however, don’t “replace the value of clinicians carefully reviewing and reading a drug name and dose,” she said.”

It’s good they made some systemic redesign changes, but they are still telling clinicians to be careful. That didn’t work before, did it?

“Cedars-Sinai has long used a “double-check system” requiring two licensed healthcare professionals to verify independently any medication before administering it, Elbaum said.”

So much for the doublechecks. When you have rare or unexpected errors, complacency can result. It’s a normal human reaction, so we have to design systems to account for that.

You can install bar code systems, as the article suggests, but there are many workarounds and ways that nurses are able to avoid the time involved in using those systems. The nurses are often overworked, so we have to get waste out of the processes to free up more time for them to do things the right way.

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The last Toyota Plant I was in had a final inspection area where the vehicles were tested and gone over by a final inspection team before being signed off. If a defect was found the team leaders, were called over, signed to acknowledge that it was a problem and have until the start of the following shift to put in place a means of preventing them.

Three of the same defects were grounds for dismisal.

This was a US plant.

There are a number of issues here, the ease of packing in the pharmaceutical company, the cost, both of which are clearly designed to keep costs to a minimum not improve safety.

If you want to address issues like this it has to be at the root cause and that is not the nurses, doctors or other professionals but at the manufacturing level.

In the last few years every major automotive manufacturer has moved to different size holes for diesal and petrol. (You can make the mistake one way but not the other)

Whilst this is not ideal it’s an issue that has been addressed industry wide and it is far easier to do that, than to train millions and millions of clinical staff world wide on how to use account for all of the variances between equipment.

One example of this that Atul Gawande refers to is the manufacture and standardisation of Anaesthetic equipment.

These things can be done, I agree its not about punishing the person (although sometimes disciplinary action is clearly warranted), but about putting in place systems that prevent these errors from occuring.

As to the comments about TPS or Lean being the way to go, Bob Wachter at Wachters world has written a brilliant blog on this very subject and as a Lean practioner I tend to agree with his own thoughts on the matter. (google wachtersworld)

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