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It is events such as this that cause one to pause and ponder the fact that as designers, especially those whom are involved in product design, we do have the responsibility to be involved and to educate. Perhaps I am blowing things out of proportion, but in this instance I doubt it.
Quoted from an e-mail sent by Francois-Xavier Nsenga
Several hundreds of ex-patients in hip surgical wards in Quebec
hospitals are soon being recalled for investigation of an eventual
contamination by HIV and other infectious diseases, due to a badly
sterilized surgical instrument. The whistle was recently blown by an
employee in one hospital sterilization department, signaling that the
particular instrument is currently not being properly sterilized,
simply because it is not, as it should normally be, completely
disassembled after use.
One of the interviewed PR medical doctors showed us last evening in
public media the incriminated instrument, and
declared: "...obviously, there is no way one could know that this
head - of the instrument - is detachable ..."
The employee in the sterilization department found out, by chance,
probably through routine manipulation, that the head of the
instrument could be removed, and all components thoroughly sterilized
One is thenn tempted to conclude that no competent design work was
done at the successive life phases of the instrument use, "from the
cradle to the ...". Quite obviously there has been incomplete design
input in the early briefing phase and at the drawing board or
software designing phases. One could add also that no full design
supervision has been ensured during the manufacturing process of the
instrument, and definitely no design intervention at the time of
multiple government inspections and approval procedures. Had research
and practice designers been adequately trained to "sell" their
expertise to medical equipment vendors and government approval
officials, to hospital purchasing agents and medical personnel
training teams, most probably the whole present mess would have been
avoided, or at least the damage greatly limited.
We are told the surgical instrument has been in use for a couple of
years without proper sterilization, and it is believed it has been
sold and used not only here in Quebec but surely elsewhere in Canada
and in other countries. One of the expected outcomes is the financial
disbursement that will be estimated in millions of dollars after
legal responsibilities and indemnification will be ascribed. But
there also are inestimable social effects (increasingly diminished
confidence of citizens in public institutions) and emotional
catastrophes resulting from the agonizing anguish of all those
individuals who might have been (or not!) infected and having (or
fear of!) spread the deadly diseases to loved ones.
Another case for reflection by all of us, each from our respective
sub-fields of design involvement.