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.

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.

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.

“Food and Drug Administration officials said Monday they have new evidence that links hundreds of serious adverse reactions and scores of deaths among patients given the blood thinner heparin to a man-made contaminant introduced during production in China.”

Heparin just can’t win.
http://www.newsobserver.com/nation_world/story/1045502.html

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.

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