Death from Branding

If you’re Apple, you want people to see the similarities between their iPod and their iPhone. However, if you are a drug manufacturer, you do not want similarities between adult and pediatric medicine.

Above are bottles of Heparin, manufactured by Baxter Healthcare. Both blood thinners, one of these vials is 1,000 times more concentrated than the other. Confusion between these two bottles killed infants at an Indiana hospital back in 2002. This article provides a good overview of past cases.

I actually remember reading about this back then, and thought “Wow, there’s a good human factors lesson. How awful that children had to die to bring it into the spotlight.”

Unfortunately, this lesson stayed unlearned, as two more children were administered the adult drug this week. Because these were the newborn twins of Dennis and Kimberly Quaid, who have already spoken out on 60 Minutes about medication mistakes, we may see the problem addressed more thoroughly in the drug industry.

On a final note, these cases touch on the human desire to blame other humans rather than the systems they interact with. In the Indiana case, a mother who lost her child was quoted as saying:

… who blames the nurses, not drug labeling, for her daughter’s death. “I don’t think it was from the label,” she said. “They are both blue, but one is lighter than the other. How could they mistake those?”

Change blindness, automaticity, expectation, fatigue, and time pressure are but a few of the factors that might have caused the error. Sometimes, it isn’t a case of someone not just “being careful.” This is actually a good thing: we can understand and solve human factors problems. We can’t make someone care.

9 thoughts on “Death from Branding”

  1. I agree that it is terrible it seems to always take an accident for these issues to be addressed. In a perfect world, the medicinal manufacturers would do more comprehensive user group research for something as vital and dangerous as hospital-administered medications… perhaps some reading on male and female workplace stress levels and intake of visual cues might have done them some good! And sheesh, how do the color differentials even register for someone who is colorblind? While tritanomoly (yellow/blue colorblindness) is rare, it is still a factor! 🙂

    Thanks for this fantastic blog, human factors is a passion of mine and it’s always wonderful to discover others who feel the same.

  2. Welcome Ryan. I think simultaneous stress and workload that nurses/doctors are under are important issues. I wonder if a textured label would enhance discriminability? I assume the actual shape of the bottle is impractical or costly to change.

  3. Interesting idea about the texture. A rough label for the higher dose might be a good trigger to let them know all is not usual.

    In one of the cases, it was also said that the closet had never been stocked with the adult doses, so the nurse who grabbed it had no experience in having to differentiate.

  4. Yes I saw that! I was shocked!

    Also though, I love the idea of the textured labels. Being able to feel the texture difference through latex/latex equivalent gloves would be a factor, but one that could be accounted for, definitely. Typically changing the actual shape of the bottle for liquid medicines is more of a customs/shipping issue, more than a cost issue from what I understand. Being able to air/freight ship large quantities of small glass bottles with minimim breakage, leakage and batch contamination (which, I suppose, -is- a cost issue, heh).

    Thickness of the glass ratio to size of bottle creates a very strong vessel… but I don’t see why they could not be molded with small bumps or ridges on the outside of the glass for differentiation… unless these same bottle shapes and sizes are shared with other liquid medicines by other manufacturers… which many do, from what I understand, to keep cost very low, instead of making your own mold and producing your own runs.

    Which is probably what Richard was getting at. 🙂

  5. Let’s hope we don’t need blood thinners!

    The gloves and cost issues are very good points. Obviously Baxter watches their costs. I like to “speak with my wallet” by not supporting bad design (or lead contaminated medicines) but somehow I don’t think anyone is ever going to give me a choice of blood thinners when I’m lying in the hospital.

  6. I had an interesting discussion last night about this issue with my mother in law, who is a 26-year-veteran nurse. As Anne stated above, “the closet had never been stocked with the adult doses, so the nurse who grabbed it had no experience in having to differentiate.” This is a major automation error that is all too common in hospitals.

    In order to function efficiently and safely in the high-stress emergency room setting, nurses learn to rely on their automatic pilot; grab the gloves from this drawer here, get the vials from this shelf here, get the medicine from this cabinet here, admininster medication, throw away vials in this trash can, throw away gloves in this other trash can. Mark chart. Put chart on door. Check vitals. Check fluids… list goes on and on.

    Thousands of simple tasks that must each be performed a certain way to achieve a common purpose, and any minute task performed incorrectly (even something as simple as making a patient’s bed) has health, safety, and most likely legal consequences… and maybe 30% of the time, at best, you have the time to check your work.

    I think it’s the ultimate Human Factors challenge to design for this environment. If I had a choice of what to do a thesis on, it would definitely be emergency room-as-workplace employee task analysis. 🙂

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