Tuesday, November 17, 2009

Chemotherapy errors - human factors design, management problems

So it appears that the problem is related to the fact that the two pumps looked identical.

" Mr Khaw laid the blame on the similarity in appearance of the two pumps which were mixed up, and said that he would be providing feedback to the manufacturers.
He said: ‘The pumps look almost exactly the same…This is very dangerous when there are two pieces of equipment and one is millilitre per hour, and one is millilitre per day – you are causing unnecessary risk to the users of this device.’
The key thing, he emphasised, is to learn from this incident and prevent similar mistakes from occurring. "

While it is right that the staff involved should bear some responsibility for being careless, Minister is right in not over apportioning blame on the hands that pulled the trigger.

A significant part of the responsibility should lie with the manufacturers, who were too dumb to design their pumps properly. Did they not consider the user in their design? Sadly it is too common to see engineers in their rush to get a working piece of equipment out into the market place, sacrifice all human factors considerations. It doesn't matter if the user gets into all kinds of problems, or have difficulties in getting the equipment to work properly. This is something I hope the new Singapore University of Technology and Design will address. It's not just a matter of getting an innovative product out into the market place, it is about getting a well designed product out. One that takes into considerations the needs of the user. This is called Human Factors Engineering.

Yet another part of the responsibility should be borne by the management. Did they not see this as an accident waiting to happen? Did it not seem clear to them that if you have two pieces of equipment looking exactly like each other, some one's going to make the mistake of using the wrong piece of equipment? Did they not do a risk assessment of the procedures they used in the chemotherapy unit? Even though the design of the equipment left a lot to be desired, they could just as easily have stuck on a strip of red tape distinguishing one from another. A simple solution that could have prevented this disaster. Just that nobody bothered.


Anonymous said...

Have you considered the 'incident' rate of the failure? If there is a problem with the pump design, let Mr Khaw pull out some statistics from here, overseas to see the error rate.

Do not brush off the 'responsibility' unless you can prove facts.

gigamole said...

Please don't get me wrong. I am not excusing the operator from the mistakes they made (I do believe they have been 'posted out'). No mater what problems with design and what not, the error was one that arose through carelessness.

What I am advocating is a more enlightened approached where management and equipment design are considered as well, as part of the environment that contributed to the error.This is the approach taken when flight accidents are investigated.

It is always too easy to just lay all the blame on the operator.

Anonymous said...

Khaw is wrong on the facts. The pumps used were programmable for hourly or daily rates. The error was in the programming. After the incident, these were changed out for dedicated pumps that dispenses hourly or daily rates. Of course, Khaw's information was based on what KKH told him.

gigamole said...

ahh...sou desu ne?
How interesting..... management playing games, eh?