Technology led a hospital to give a patient 38 times his dosage

I saw it right away. That said, I agree with the article that the UI is horrible. It (and many other elements of this story) remind me of interacting with Enterprise software, although in that case people usually aren't in mortal danger because of it.

I probably noticed it more because I saw the first screenshot with a "5" in the same box and thus "160" looks surprising, but even without that first screenshot I would probably have noticed --- the "mg/kg of trimetho" with a search(?) button doesn't make sense. Why would you want to search for that phrase, and why is it cut off like that? Another sign of "Enterpriseness": the two buttons next to it, presumably to set standard doses, have huge amounts of empty space surrounding them, while the inexplicable "search box" is too small to contain its expected contents.

Of course, it could leave the unit [mg versus mg/kg] box blank [...] but few systems do that because of the large number of additional clicks it would generate

That makes no sense. As any science teacher (or at least the good ones) will make it known very very clearly, units are important! I can remember a few incidents[1][2] that occurred because of units confusion.

Had Lucca noticed it, she could have changed it to “mg” with two clicks

Two clicks? Just looking at it, this UI is not obvious at all to me how to even change the units. Do you type in "mg of trimetho..." in the "search box"? After thinking about this for a tiny bit, my proposal would be either radio buttons for each unit, with no default, or two text boxes, one labelled "mg" and the other "mg/kg", where editing one instantly updates the other.

We also needed to address another problem that is not limited to healthcare: overtrust in the technology

Or more generally, a lack of thinking; people who are taught to follow procedures or "best practices" for the "best results" are only going to follow them unquestionably. It's unfortunate that a lot of the time the management above only points to a lack of procedure when it's actually this "overproceduring" which can cause such errors --- the incident where NASA's satellite fell over[3] is one example of this. No one thought to even take a look to see if they had secured it, everyone was too busy executing lists of instructions. If they weren't, and just given a general description of what they needed to accomplish, I'd be pretty sure they would at least check the mounting before trying to turn it on its side.

[1] https://en.wikipedia.org/wiki/Gimli_Glider

[2] https://en.wikipedia.org/wiki/Mars_Climate_Orbiter#Cause_of_...

[3] https://en.wikipedia.org/wiki/NOAA-19#Damage_during_manufact...

Meanwhile that same technology has replaced a reportedly convoluted and error-prone manual process that presumably worked perfectly and never harmed anyone, otherwise surely the authors of the article would have gone into that.

The majority of errors are caught — by the prescriber, by the pharmacist, or by the nurse administering — but a few fall through the cracks. Order of magnitude errors, where the dose is x10^n the intended dose are some of the more common errors.

We have a lot of safeguards — for example packaging medications in dosages that are likely to be safe for a single dose — but there are also some factors that make errors more likely, such as paediatrics (who need smaller does), geriatrics (who often have many different medications which can interact), and critical care (where things move fast, and big doses might be needed).

I'm a student doctor, and hopefully you believe me that medicine is hard. Electronic systems might help with some of the hard bits, but they're often a hindrance, or pose their own hidden dangers. As a software engineer I know that a lot of medical software is far from fit for purpose.

> [...] But even in simplified form, you can see why the old system was hugely error-prone. A study from the pen-and-paper era showed that 1 in 15 hospitalized patients suffered from an adverse drug event, often due to medication errors. A 2010 study (using data collected during the pre-digital era) estimated the yearly cost of medication errors in U.S. hospitals at $21 billion.

> Those of us who worked in this Rube Goldberg system — and witnessed the harms it caused — anxiously awaited the arrival of computers to plug its leaks. [...]