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Comment by Someone1234 | Hacker News Reader

While I absolutely agree computers, UIs, and systems in general can stand between a patient and an error, can we just stop and acknowledge how incompetent the doctor was for prescribing 38 instead of 1 double strong dose?

The UI screenshot in the article makes that mistake VERY clear, and their "are you 100% sure" question is obviously intended to illicit a particular response (who is ever really 100% sure of anything?).

I know this article is about how systems can be altered to protect patients, but much like with the NTSB's findings, sometimes it legitimately is pilot error (or doctor error in this case).

Can things be better? Yes. Absolutely. But so can doctors. These types of systems are stop-gaps, without them this doctor could have calculated the wrong dose by hand and made just of large of a mistake.

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Yes, the doctor and pharmacist and administering nurse failed here. But that is not useful. The useful bit is why they failed, and that seems to be a mix of "busy" with "software sucks".

The doctor didn't order 38.5 tablets -- at least she didn't think she was. She thought she was ordering a dose per kg, not a quantity of tablets.

You say the screen is very clear. It's clear enough when I read it. I had a good night's sleep and I am alert and awake. I've been primed by the article to look for the error. I imagine I would easily miss the mistake if I've been working hospital wards for the last 10 hours on a rolling nightshift, looking after some very ill patients.

The fact that it's possible to use two entirely different dosing systems to order medication and have the screen not clearly indicate[1] which is being used is so obviously sub-optimal I'm kind of surprised to see anyone saying that it's "just pilot error".

> She thought she was ordering a dose per kg, not a quantity of tablets.

Actually, she thought she was ordering a single dose at 160mg, and accidentally ordered dose per kg. 160 was the size of the dose, so the patient's weight became the number of pills.

If someone works with a piece of software every day, they're going to start navigating it by the position of elements in the software, not what the text around the elements say. If the "erase form" button was placed below and to the right of a web form, where the "submit" button usually is, you bet it would cause a fair amount of swearing.

If the doctor is used to working with older/larger patients (over 40kg) they might get that screen only rarely, and perhaps because the patient was so close to 40kg, she wasn't thinking in "pediatrics" mode, and expecting it to come up.

Yes it is obviously an error by the doctor and the pharmacists, no one is saying otherwise. The whole point of the article is to investigate how this error occurred. We live in a world where these errors happens all the time and the best thing we can do is learn from them and if the error analysis boils down to "incompetent doctor", then it is likely that the same error will occur again.

> and their "are you 100% sure" question is obviously intended to illicit a particular response (who is ever really 100% sure of anything?).

When you routinely get prompted with that question dozens (hundreds?) of times a day, it can't elicit that response successfully. It's just not how our psychology works.

I'm not sure I follow. The author of that article asked people that question at conferences when showing them the UI screenshot in the article.

Misunderstood; I thought you were defending the confirmation prompt in the software itself.

You should actually read the article.

You should actually post a specific criticism. I did read the article, that is my take-away. I'd respond to your issues with my post but you forgot to let us know what they are...

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