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.