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Give me a break. The system has alerts and it spells out the exact dosage in tablets in a dozen places, which is then apparently seen by at least three people.

Give me a break. The system has alerts and it spells out the exact dosage in tablets in a dozen places, which is then apparently seen by at least three people. If these people in the course of their work choose to ignore alerts, are distracted and not actually doing what they were hired to do (hint: theres a reason there were three humans in the chain here), the fault lies on them, not on the software. You obviously can't have it both ways. We call it automation because things will happen automatically. At the end of the day, this system probably causes significantly less problems than the old way of trying to read some doctors handwriting only to pick up the wrong medicine regardless.

jsprogrammer 12y ago
Don't forget about the unwritten 'real policy', as opposed to the actual policy: >Every training program has a “hidden curriculum” (the way things are actually done around here, as opposed to what the policies say or what the administrators told you during that interminable orientation). One of them — passed down from senior residents to the newbies — was, “Ignore all the alerts.”
llamataboot 12y ago
Really, you think the UX of those screens is in anyway clear or that the alerts shouldn't be color coded or differentiated by thresholds from "hey this looks like it might be an error" to "this is out of the realm of possibility, do not pass go, do not collect 200, correct this immediately"
- isaacdl 12y ago
  But who gets to set the threshold? One doctor might want a full stop at 3% over, one might want one at 10%, one might not necessarily want one until maybe 50% (perhaps in this case of a research hospital that is routinely trying experimental treatments). I don't disagree that this shouldn't be considered carefully, but it's a little harder than maybe you're making it seem.
  - llamataboot 12y ago
    Oh, I think it's incredibly complex. I think UI/UX is a huge difficult field and these things always have tradeoffs - not only in terms of usability but in the overhead of being the people tasked with building them. In fact, UI/UX may be the hardest set of tasks we now face as as people making software products that other people use. But if you think /any/ information is easy to see in that rat's next of anti-design, I think you're wrong. I
- revelation 12y ago
  All I'm seeing is that the salient information is on the UI in at least three places. It spells out the freaking calculation. So clearly, these people simply didn't look. Not once. In their perpetual multitasking frenzy that any hospital staff seems to be in, they didn't do the actual task. I'm reasonably sure that you can color code or flash whatever yo u want and they would still miss it if that's the way they work.
  - wyldfire 12y ago
    A graphical representation of the dose relative to the patient weight or the dose prescribed relative to the recommended dose would be a great way to help users from accidentally making this mode error.
ams6110 12y ago
Not true. Alerts are both distracting, causing fragementation of focus and attention, and eventually mentally filtered out. Our brains are wired to ignore stimiuli that are not relevant to our current focus. It's very unwise to expect people to be able to consciously override nature all the time. I still don't understand how the nurse administering the dose would not have been alarmed that the kid was apparently supposed to swallow almost 40 pills at once. That's the sort of unusual situation you WOULD expect a human to notice right away.
- revelation 12y ago
  I get it, you start ignoring alerts when theres so many of them. That's also the moment you go back to whatever manufacturer and tell them that you can't work with a safety critical software that will emit spurius alerts to no end. What you can not do responsibly is to simply ignore all of them and then claim that somehow it's the fault of the software. Yes, as it turns out, you actually take on responsibility when you work in these kind of areas. I personally would never agree to code for systems that end up radiating humans or other safety critical systems.
  - DanBC 12y ago
    > I get it, you start ignoring alerts when theres so many of them. That's also the moment you go back to whatever manufacturer and tell them that you can't work with a safety critical software that will emit spurius alerts to no end. Who do you think buys the equipment or has contact with the vendor?
tjradcliffe 12y ago
> If these people in the course of their work choose to ignore alerts This is where your mistake is coming from. You think for some reason that people are choosing to ignore the alerts, rather than being habituated to ignore them. It is theoretically possible for a person with a decade or so of training to maintain a constant level of attention on repetitive trivia. Studies on Buddhist monks have shown this. But the people who were doing this didn't study Buddhist meditation, they studied medicine, so expecting them to behave like Buddhist monks, which you seem to be doing, is the height of irrationality. Humans have very limited attentional resources and extremely powerful internal non-conscious filters to conserve those resources that can only be overcome by lengthy and rigorous training, which would exclude the kind of training these people actually needed to do the rest of their job. These are just facts, well-established by a wealth of empirical research over the past several decades. Responding "Give me a break" to a system whose failure was fully predictable based on known facts of human psychology and physiology is precisely the problem. Perhaps someone on the design team pointed out the issues, and were told by someone who knew nothing about human psychology beyond what their gut told them, "Give me a break!"

jsprogrammer 12y ago

Don't forget about the unwritten 'real policy', as opposed to the actual policy: >Every training program has a “hidden curriculum” (the way things are actually done around here, as opposed to what the policies say or what the administrators told you during that interminable orientation). One of them — passed down from senior residents to the newbies — was, “Ignore all the alerts.”

llamataboot 12y ago

Really, you think the UX of those screens is in anyway clear or that the alerts shouldn't be color coded or differentiated by thresholds from "hey this looks like it might be an error" to "this is out of the realm of possibility, do not pass go, do not collect 200, correct this immediately"

isaacdl 12y ago
But who gets to set the threshold? One doctor might want a full stop at 3% over, one might want one at 10%, one might not necessarily want one until maybe 50% (perhaps in this case of a research hospital that is routinely trying experimental treatments). I don't disagree that this shouldn't be considered carefully, but it's a little harder than maybe you're making it seem.
- llamataboot 12y ago
  Oh, I think it's incredibly complex. I think UI/UX is a huge difficult field and these things always have tradeoffs - not only in terms of usability but in the overhead of being the people tasked with building them. In fact, UI/UX may be the hardest set of tasks we now face as as people making software products that other people use. But if you think /any/ information is easy to see in that rat's next of anti-design, I think you're wrong. I
revelation 12y ago
All I'm seeing is that the salient information is on the UI in at least three places. It spells out the freaking calculation. So clearly, these people simply didn't look. Not once. In their perpetual multitasking frenzy that any hospital staff seems to be in, they didn't do the actual task. I'm reasonably sure that you can color code or flash whatever yo u want and they would still miss it if that's the way they work.
- wyldfire 12y ago
  A graphical representation of the dose relative to the patient weight or the dose prescribed relative to the recommended dose would be a great way to help users from accidentally making this mode error.

ams6110 12y ago

Not true. Alerts are both distracting, causing fragementation of focus and attention, and eventually mentally filtered out. Our brains are wired to ignore stimiuli that are not relevant to our current focus. It's very unwise to expect people to be able to consciously override nature all the time. I still don't understand how the nurse administering the dose would not have been alarmed that the kid was apparently supposed to swallow almost 40 pills at once. That's the sort of unusual situation you WOULD expect a human to notice right away.

revelation 12y ago
I get it, you start ignoring alerts when theres so many of them. That's also the moment you go back to whatever manufacturer and tell them that you can't work with a safety critical software that will emit spurius alerts to no end. What you can not do responsibly is to simply ignore all of them and then claim that somehow it's the fault of the software. Yes, as it turns out, you actually take on responsibility when you work in these kind of areas. I personally would never agree to code for systems that end up radiating humans or other safety critical systems.
- DanBC 12y ago
  > I get it, you start ignoring alerts when theres so many of them. That's also the moment you go back to whatever manufacturer and tell them that you can't work with a safety critical software that will emit spurius alerts to no end. Who do you think buys the equipment or has contact with the vendor?

tjradcliffe 12y ago

> If these people in the course of their work choose to ignore alerts This is where your mistake is coming from. You think for some reason that people are choosing to ignore the alerts, rather than being habituated to ignore them. It is theoretically possible for a person with a decade or so of training to maintain a constant level of attention on repetitive trivia. Studies on Buddhist monks have shown this. But the people who were doing this didn't study Buddhist meditation, they studied medicine, so expecting them to behave like Buddhist monks, which you seem to be doing, is the height of irrationality. Humans have very limited attentional resources and extremely powerful internal non-conscious filters to conserve those resources that can only be overcome by lengthy and rigorous training, which would exclude the kind of training these people actually needed to do the rest of their job. These are just facts, well-established by a wealth of empirical research over the past several decades. Responding "Give me a break" to a system whose failure was fully predictable based on known facts of human psychology and physiology is precisely the problem. Perhaps someone on the design team pointed out the issues, and were told by someone who knew nothing about human psychology beyond what their gut told them, "Give me a break!"