I was the CTO for medical software company that kept track of adverse drug events and other hospital incidents. We also made software for Root Cause Analysis projects and the subsequent committee meetings. UCSF was a client at one point.
Hospitals and practitioners are incentivized to never admit they made a mistake. This article is that writ long.
The screen said what would be ordered and did exactly that. The ordering physician did not read the screen. Perhaps the screen could be better but it's not bad. The dosage is bolded.
Someone else reviews it and also doesn't notice the error. I.e. they did a bad job of reviewing.
UCSF staff had turned off notifications and alerts in a very broad manner.
The robot pharmacist gets dragged into this even though it just followed orders, in an article titled "Beware of the Robot Pharmacist". Imagine how long this series would be if the robot had actually made decisions.
At one point a nurse asks the juvenile patient if he thinks 38 pills is too much. In movies, asking a child for advice is the comic low point where we are meant to realize the adult is incompetent. This nurse kept her job.
Hospitals are incredibly political environments and this article goes out of its way to keep everyone's hands clean. But at the end of the day multiple people made mistakes and the author just decides to blame everyone's new favorite boogie man "technology".
Having seen hundreds of incident reports, I assure you that most hospital issues are caused by people making mistakes and/or not following procedures. And all signs point to that being the case here.
What would have been more helpful is if the author would have followed his own conclusion, and centered and titled the articles around it:
"Safe organizations relentlessly promote a “stop the line” culture, in which every employee knows that she must speak up — not only when she’s sure that something is wrong, but also when she’s not sure it’s right. Organizations that create such a culture do so by focusing on it relentlessly and seeing it as a central job of leaders. No one should ever have to worry about looking dumb for speaking up, whether she’s questioning a directive from a senior surgeon or an order in the computer."
Perhaps if medical leaders stopped pretending that they always do everything perfect - i.e. the opposite of this literally CEO approved article - people further down the ladder would feel they could also be honest.