Con­fus­ing and danger­ous

Modern Healthcare - - NEWS -

A blood sugar reader used in a MedS­tar Health hos­pi­tal gave this con­fus­ing pop-up. The dig­i­tal de­vice read: “Crit­i­cal Value, Re­peat Lab draw for >600.,” which seemed to in­di­cate the pa­tient’s blood sugar was crit­i­cally high. The pop-up warn­ing vis­ually blocked the de­vice’s true read­ing. The pa­tient’s blood sugar was ac­tu­ally ex­tremely low, and the re­sult­ing er­ro­neous treat­ment sent the pa­tient to the ICU. Hu­man-fac­tors en­gi­neers de­ter­mined a clearer mes­sage could have helped pre­vent the in­ci­dent.

Rec­om­mended dis­play

Ac­tual dis­play

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