3 ms·

There are least two comments here already ascribing the error to incompetence; I expect more will come. In my opinion, this is a dangerous misperception. Hind

by comex 12y ago

There are least two comments here already ascribing the error to incompetence; I expect more will come. In my opinion, this is a dangerous misperception. Hindsight is 20/20. You saw one screenshot displaying the incorrect dosage; the doctors see "scores" each day, day in, day out. The brain is hardwired to ignore repetitive stimuli. Humans are smarter than computers overall but have a much higher error rate; "competence" can decrease that rate, but not to zero. There is always a chance of a mistake. The software could have been designed to make the probability of requesting a 38.5x overdose from the robot pharmacist negligible, by reserving a special warning for extreme circumstances. This requires the programmers to do a non-shit (shall I say "competent"?) job once, but not constant vigilance by the doctor, who I'm sure can use the saved mental cycles to check for many other potential errors the machine can't handle completely trivially. I expect a more thorough design overhaul would cause a non-negligible reduction in the occurrence of a wide variety of mistakes, dangerous and not.

FireBeyond 12y ago
There was a remark made by one of those involved, in the article, that EPICs alerting didn't differentiate between a 'trivial' alert, say "Dose is 1.02x maximum recommended dosage" and a much more critical "Dose is 38.5x..."
- bentcorner 12y ago
  A scale would be useful: Recommended dosage | ----|-x------------ vs ----|------------x- Also for mg vs mg/kg, that's a harder problem - off the top my head, get rid of the modes, and show both mg/kg and mg textboxes, with a radio button to select the one you want to edit. Edit it, and the non-selected text box is grayed-out and uneditable, and shows you the corresponding calculation (enter in mg/kg, and it shows you the mg amount of medicine; enter in mg, and it shows you the mg/kg ratio).
  - maddog99 12y ago
    As a sanity check, what about showing the ordering physician a picture of 38.5 tablets? "Is this correct?" I think that would grab my attention.
PhantomGremlin 12y ago
> The software could have been designed to make the probability of requesting a 38.5x overdose from the robot pharmacist negligible, by reserving a special warning for extreme circumstances A special warning is good. But the software could ALSO require the doctor to, instead of just clicking, read a message like this on the screen: YES I REALLY WANT A DOSE OF 6160 MG OF (whatever) Then force the doctor to re-type that exact message into an input field. Typing required, no cut/paste allowed. There is nobody, no matter how busy, who would type those words without thinking about what they are doing. Of course, that sort of typing can't be requested routinely, only in extreme circumstances. Perhaps these extreme circumstances would require TWO people to type that same message? Or, maybe the software should simply REJECT a dosage greater than perhaps 10x safe dosage for a person. No override allowed?

by comex 12y ago

FireBeyond 12y ago

There was a remark made by one of those involved, in the article, that EPICs alerting didn't differentiate between a 'trivial' alert, say "Dose is 1.02x maximum recommended dosage" and a much more critical "Dose is 38.5x..."

bentcorner 12y ago
A scale would be useful: Recommended dosage | ----|-x------------ vs ----|------------x- Also for mg vs mg/kg, that's a harder problem - off the top my head, get rid of the modes, and show both mg/kg and mg textboxes, with a radio button to select the one you want to edit. Edit it, and the non-selected text box is grayed-out and uneditable, and shows you the corresponding calculation (enter in mg/kg, and it shows you the mg amount of medicine; enter in mg, and it shows you the mg/kg ratio).
- maddog99 12y ago
  As a sanity check, what about showing the ordering physician a picture of 38.5 tablets? "Is this correct?" I think that would grab my attention.

PhantomGremlin 12y ago

> The software could have been designed to make the probability of requesting a 38.5x overdose from the robot pharmacist negligible, by reserving a special warning for extreme circumstances A special warning is good. But the software could ALSO require the doctor to, instead of just clicking, read a message like this on the screen: YES I REALLY WANT A DOSE OF 6160 MG OF (whatever) Then force the doctor to re-type that exact message into an input field. Typing required, no cut/paste allowed. There is nobody, no matter how busy, who would type those words without thinking about what they are doing. Of course, that sort of typing can't be requested routinely, only in extreme circumstances. Perhaps these extreme circumstances would require TWO people to type that same message? Or, maybe the software should simply REJECT a dosage greater than perhaps 10x safe dosage for a person. No override allowed?