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0 pointszamadatix7y ago0 comments

I fail to see how the quote that she didn't question it beyond thinking it must be dilluted is an example of how she question giving someone 38 pills beyond "must be dilluted".

Is any other line here actually relevant to technology or just how errors end up occurring even though you have resilient systems and checks built in? I.e. what about any of those has to do with technology itself?

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darpa_escapee7y ago

> I fail to see how the quote that she didn't question it beyond thinking it must be dilluted is an example of how she question giving someone 38 pills beyond "must be dilluted".

From the above:

> The idea that the Septra might have been diluted was the first of many rationalizations that Levitt would formulate to explain the unusual dose and to justify her decision to administer it.

If you read the rest of the article, and not just what I've selected, there are multiple points in which the author quotes the nurse about her decision making process.

zamadatixOP7y ago

I read all of the parts before making my first comment in the thread. I think you and I must disagree on what I meant by questioning the large dosage. I don't mean it as a thought exercise involving just the nurse trying to figure out why the dosage is so irregular rather the physical questioning process of validating the odd dosage with the assigning doctor before prescribing.

I pointed it out not to say it's all the singular nurses fault but rather something glossed over in an article written against a technology system that had it's safeguards purposefully disabled. If anything the human error presented in the article is many times greater than technology error, reading the headline I expected the pill robot to have some error relating to batch size or some code error converting units wrong not a single confusing UI element as part of a string of overall hospital process and validation errors.

fucking_tragedy7y ago

The way I see it is even if the machinations of the process worked 100% in accordance to their specification or programming, in the end what matters is how people will respond to the system. If a system correctly shows a warning when a bad prescription is ordered, it is still faulty if the overall system encourages the user to ignore warnings.

In this case, the system must deal with human error. The system must factor in the fact that the people who interact with the system are UI/UX laymen, they're most likely overworked and sleep deprived. Perhaps it should not offer the option to override warnings. Perhaps warnings should be expressed in such a way that the user doesn't learn to ignore them in order to do their job

Perhaps fault falls on EPIC for allowing errors to be suppressed, or for having a UI that allows prescriptions to be written with ambiguous units, or the hospitals IT staff for suppressing the warnings. The argument can be made that the hospitals upper management can be blamed for hiring and scheduling practices that result in staff overworking or having to ignore software warnings.

All I know is that blaming human error has been tried for decades and results haven't changed. Maybe the overall system, top to bottom, needs to be reworked.

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