My At-Home Medical Mistake

I’m a bit mad at myself for inflicting some preventable human error on myself last night. It’s OK, I didn’t harm myself, but let me tell the story.

I’ve been battling what’s either severe allergies or a mild cold for three or four days. I’ve alternated a bit between the daytime and nighttime formulas of a major branded OTC cold/congestion pill. Last night, I was in bed and couldn’t sleep, I was wired. I thought, uh-oh, got up to check and, sure enough, I had given myself non-drowsy daytime formula.

The upside is that I went out to the home office and got a lot of work done, but I’m dragging this morning.

What has me kicking myself… I didn’t practice what I preach in the Lean methodology!!

I had a “near miss” the night before. I had made the exact same mistake the night before. I had caught the error right after popping the pills in my mouth, I spit them out and took the nighttime formula. I’m mad at myself for not fixing the root cause of the problem. I didn’t move the daytime formula off the bathroom counter, making it harder to mistakenly grab the wrong on while getting ready for bed. I did what so many people do in healthcare, because of time pressures, fatigue, or because of just human fallibility. I didn’t take the time to really prevent the problem from occurring again. Obviously, the stakes aren’t very high in the case of OTC cold medicine.

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I’m doubly human. 1) I took the wrong pill and 2) I didn’t think to take preventative measures!!

That said, looking at the packaging of the two formulas, there’s some room for confusion (again, the “severity” score for the FMEA calculation of the RPN would be low for this one). The outer box of the daytime formula used to be primarily yellow (somewhat indicating “day”) and the nighttime formula used to be primarily blue (indicating “night”). But the packaging changed to be more consistent, and that color coding is less prominent in the corner of the box. The backs of the blister packs are all white, being basically identical, except for some small text.

There *was* some color coding of the pills themselves, which should have been a tip off. The daytime pills are white, the night time cold/head congestion pills are blue. But, the color coding is NOT consistent among different products in that brand family. The “sinus congestion/pain” formula is green for day, white for night, when they come in the dual-boxed pack that includes day and night formulas. Strangely, when you buy daytime “sinus congestion/pain” on its own (without night), the pill is a green/white caplet. Why would they manufacture two different forms of the same pill?” The “sinus congestion/pain SEVERE” formula has white pills for daytime.

Seems like an opportunity for some standardization. Or time for me to quit obsessing about it, time to get to work!

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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an book titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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2 Comments

  1. David says

    Mark, I wonder why when your body is pulling the Andon Cord to tell you that you are ill and it’s time for your immune system to get to work and fix the problem, you ignore it and take medicines to keep going? Maybe if you had stopped and let your body sort itself out, you’d have been back up and running quicker and better than you are now.

    I know, I know, you are a busy man. Can’t afford to stop, lots to do. Anyway, for all I know, you did take some time out, it’s not clear from your post. Forgive me if I am being cheeky. I just couldn’t resist the analogy.

  2. Mark Graban says

    Point well made! I think we should all challenge ourselves, as lean people, to do proper preventative maintenance on our body and spirit. Doing routine maintenance prevents major breakdowns, eh?

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