When bad design goes horribly wrong.

blank's picture

Over at Cedar Sinai 13 patients, including celebrity twins, have been given massive doses of an anti-coagulant because a nurse grabbed a bottle without looking at it.

What does it really take to make the general populace aware of how dangerous bad design can really be? The recent coverage of the new Target prescription bottle and Highway Gothic got the ball rolling, but how do designers get business to really appreciate that letting someone design better labels and containers can prevent disasters? Should we be lobbying MBA programs to teach a course in the value of design? Or would it be better taught to lawyers, who might advise their clients that this can prevent a lawsuit? Does anyone have connections at 60 Minutes?

Ricardo Cordoba's picture

Not to dimiss the issue of bad design, but in this case, was the culprit really bad design, or just a distracted nurse?

blank's picture

I blame bad design. Hospital staff are notoriously distracted, enough so that now and then someone gets sutured up with surgical equipment left inside. So why are the bottles of a drug sold in different strengths not obviously designed to reflect the contents? Something as simple as color-coded bottles, labels, or lids could make a big difference. So could stating important information right-side-up and upside-down, so that when a nurse or doctor flips the bottle to fill a syringe, the label can be read during the pause.

It just seems like this should be so easy, but all I ever see are little glass bottles with simple labels and steel lids.

crossgrove's picture

I have to agree with Ricardo; lack of education and media saturation seem to have produced an environment where people don't listen, don't try to read what's written in front of them, and to top that off, look for scapegoats to blame when someone has done something hideous like give anticoagulants to random people. It's the fault of the nurse, shouldn't that be clear?

I went to pick up a prescription, and the pharmacist looked at my drivers license 4 separate times before she actually read the letters of my name, instead of reading what she expected to see. Crossgrove isn't the same as Cosgrove, and it's not my fault, or the fault of DMV, or type designers, that she wouldn't just calm down for 3 seconds and read. There are words in every language that look similar; that's not some kind of unfair surprise. Certainly not to someone who has learned a foreign language.

their is not there
tenet is not tenant
peak is not peek
discrete is not discreet
your is not you're

blank's picture

OK, I’m going to admit to my own stupidity here. I tracked down some images of Heparin bottles and it seems to be sold in some pretty well-designed bottles. Some of which are even color-coded. So it is a user error.

Don McCahill's picture

> I blame bad design.

Please don't. A lawyer might hear you and decide to start throwing designers into the class action suits they are so eager to initiate. The last thing we need is for designers to have to have their work vetted by lawyers to make sure that a law suit is not possible.

Lawyer: Sorry, you are going to have to set that section in bold, and this section in all caps, and that bit over there should be underlined ... twice.

Designer: Well, that will look like hell.

Lawyer: Sorry, it's that way or you are open to a law suit.

aluminum's picture

"I have to agree with Ricardo; lack of education and media saturation seem to have produced an environment where people don’t listen, don’t try to read what’s written in front of them, and to top that off, look for scapegoats to blame when someone has done something hideous like give anticoagulants to random people."

Then what argument is there for good design? If the solution is to just get people to read everything, then why not make it an all-text world? Hell, why even bother with different fonts?

Of course, an extreme argument, but I think blaming just the nurse is an extreme argument as well.

Yes, nurses should pay attention. Yes, they shouldn't be so overworked. Yes, we should use design to assist them whenever we can.

Ricardo Cordoba's picture

a nurse grabbed a bottle without looking at it

It says she didn't look at it, so in this particular case it is her fault. :-/

But back to bad design -- as I said earlier, I didn't mean to understate the importance of design in certain situations where it can and does affect people's lives... Like road signs.

Ehague's picture

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pattyfab's picture

I still blame bad design for the 2000 election - the butterfly ballot caused thousands of West Palm Beach Jews to vote for Pat Buchanan, which even he acknowledged must have been a mistake.

Talk about horribly wrong.

russellm's picture

Somewhere in all the commentary about the recent Taser incident at Vancouver Airport was a single comment about how badly designed that airport is. The person said something to the effect that it was very difficult and frustrating to find your way around there even if you speak and read English and that he could understand how a person could become distraught.

Bad design may not be the cause, but it can can lead to disastrous consequences. One must to design medicine labels with the understanding that nurses will be distracted and airports so that people don't get lost.

Here's something about medicine bottle labels from Design Observer

Ricardo Cordoba's picture

Patty, Russ... Those are great examples.

Ricardo Cordoba's picture

Oh, and getting back to the original question James posted,

...but how do designers get business to really appreciate that letting someone design better labels and containers can prevent disasters?

The best example I know of this comes from Jorge Frascara. He gave a talk at my university once, and told us that where he lived in Canada, collecting statistics of highway accidents made the government stop and consider a program to improve signage, its legibility, etc. Probably not an example you can apply broadly, since it happened in Canada and the government was the client... but it is still a real-life example. Look at the Clearview project... It's taken them a while to convince state authorities, but they are slowly coming around.

It's clients that need convincing, since they are the ones with the power to approve these kinds of jobs.

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