Confusing and dangerous
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.