Tag Archives: history

This Human Factors Problem Should Be History By Now

An old problem has hit the news again: chemicals that look too much like drinks. This story just came out in New Jersey, where six people drank tiki-torch fuel the color of apple juice.

It is an interesting problem… what SHOULD you make fuel look like? The tiki-torch fuel bottle did not fall into the Fabuloso problem of looking like a sports drink bottle*. It wasn’t being kept under the bar, like the caustic dish liquid that scarred a father and daughter in “Set Phasers on Stun.” It doesn’t taste sweet like anti-freeze.

Yet when six people all make the same mistake, in a short time span, in a wide geographic spread, are of different ages, etc., it’s safe to assume something triggered them to think it was drinkable. As the executive director of the New Jersey Poison Information and Education System said in the article from the Star-Ledger:

“During my 40 years in medicine, you get an occasional kid who ingests kerosene, but I have never seen this kind of cluster,” he said.”

But what was it? From looking at the bottle, I don’t have a good answer.

*Fabuloso refused to change their bottle shape but made the concession of adding a child-proof cap. As the other stories show, it’s not just kids making these errors, but the cap should at least make the user think as they try to open the “sports drink.”**

**Of course that reminds me of the time I bought a new contact lens solution and opened it to see a bright red bottle tip. “What a neat retro-looking design,” I thought before filling the contact and putting it in my eye. An hour of rinsing later, I still thought maybe I’d blinded myself.

More medical errors–Operating on the wrong side of the patient’s brain!

There sure seem to be lots of medical errors in the news lately. No mention of human factors:

The most recent case happened Friday when, according to the health department, the chief resident started brain surgery on the wrong side of an 82-year-old patient’s head. The patient was OK, the health department and hospital said.

In February, a different doctor performed neurosurgery on the wrong side of another patient’s head, said Andrea Bagnall-Degos, a health department spokeswoman. That patient was also OK, she said.

But in August, a patient died a few weeks after a third doctor performed brain surgery on the wrong side of his head. That surgery prompted the state to order the hospital to take a series of steps to ensure such a mistake would not happen again, including an independent review of its neurosurgery practices and better verification from doctors of surgery plans.

We can surmise from the short news article that the source of the problem seems to be working memory??

In addition to the fine, the state ordered the hospital to develop a neurosurgery checklist that includes information about the location of the surgery and a patient’s medical history, and to put in place a plan to train staff on the new checklist.

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