Table Judged Reasons for Failure in Events Cited 22 XIV




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5.0FAILURE EVENTS IN OTHER SYSTEMS

5.1The Florida Butterfly Ballot (poor interface design, lack of usability testing)


The infamous “butterfly ballot” used in Palm Beach, Florida, during the 2000 presidential election was laid out and printed in such a way that when people attempted to vote for the Democratic candidate, Al Gore, many ended up voting for the Reform Party candidate, Buchanan, or for both Gore and Buchanan. Although the Democratic candidates were listed in the second item in a left-hand column, the supposedly corresponding hole to punch was the third one down in a centrally located column, where the proper holes alternated between candidates listed in the left-hand column and the right-hand column. This egregious design flaw was a simple matter of very poor human factors in laying out the ballot to accommodate a slightly simpler mechanism rather than implementing what would be simple, obvious, and natural for the human user (Vicente, 2004).

5.2Emergency MRI Oxygen Bottle Kills Child (lack of anticipation of critical safety requirements)


A child patient undergoing an MRI in Westchester Medical Center in New York needed emergency oxygen. The available supply (from aluminum bottles in the MRI facility) had been exhausted and additional oxygen was requested. A passing nurse heard the call and rushed in with a conventional steel oxygen bottle, which she should have known was inappropriate when used in areas where there are powerful magnets, such as those used in MRI. When the steel bottle was close enough to the magnet, it was suddenly pulled from the nurse’s hands by the magnet and into the MRI cavity. It struck the child’s head and immediately killed him. In the rush to provide the child with oxygen, the nurse did not think about how ferrous material is attracted by magnetism. This accident set off an immediate nationwide effort to improve safety conditions and procedures for MRI facilities (Casey, 2006).

5.3Production of New Salk Vaccine at Cutter Labs (rush to scale up production precluded precautionary care)


In April 1955, experimental evaluation results of the Salk vaccine were announced. Against the most virulent type of polio, the vaccine proved to be at least 60 percent effective, and against the more common types of polio it was more than 90 percent effective. Six pharmaceutical firms were immediately licensed to produce the vaccine, including Cutter Laboratories of Berkeley, California. The challenge was how to scale the laboratory methods for manufacturing. This included collecting and handling thousands of monkey kidneys and batch processing to deactivate live polio virus, then testing the vaccine. Cutter decided to test random batches due to costs and the urgency in making the product available. Government inspectors verified the paperwork but did not verify the product. Shortly after 308,000 first- and second-graders and 82,000 patients in medical offices were inoculated, there were problems. Two hundred and forty cases of full-fledged polio were reported; 180 of those infected were paralyzed and 11 died. The U.S. surgeon general cancelled the entire program. An investigation at Cutter pointed to “small changes” in the lab procedures originally used to kill the virus to those used in industrial-scale production. Cutter subsequently went out of business (Casey, 2006).

5.4Patient Morphine Overdose from Infusion Pump (nurses’ complaints about programming disregarded)


Patient-controlled analgesia (PCA) infusion pumps are common in hospitals, and many firms manufacture them. Nurses responsible for programming the pumps have long reported that the task is not easy, and several organizations have reported on the potential safety problems. The Emergency Care Research Institute issued an alert about PCAs being “susceptible to mis-programming” and stated that “the user interface and logic of the pump are particularly complex and tedious.” In February of 2000, Danielle McCray, who had just given birth to a healthy baby via C-section and was in good health, died of a morphine overdose from a PCA infusion pump. She had received four times the lethal dose. Subsequent investigations estimated that between 65 and 650 deaths have occurred from PCA programming errors. PCAs have a 75 percent market penetration in the U.S. Allegedly, the manufacturer told a reporter that the device “has no design flaws … the pump is safe if used as directed.” Litigation resulting from the McCray death pointed to the nurse and hospital rather than the device manufacturer. This, unfortunately, is a typical response: errors in using automation are attributed to “bad apple” users of machines rather than to the design of the machines (Vicente, 2004).
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