ABSTRACT
As in many domains, the lack of human-factors engineering (HFE) process can lead to some very unfortunate consequences in health care. A plug for pediatric EK G leads looked like it should have been plugged into an electrical socket, and was. Labels for a medication vial have “5mg/ml” in large bold type, with “5ml” as total volume in small type at the bottom of the vial. The nurse was asked to draw up and give 5mg, and gave the whole vial. Instructions for defibrillator leads on automated external defib rillator (AED) were located on the peel-away paper covers, and the wind blew them away while police man were using the AED outdoors. Consider the following quiz:
1. If it is too hard to assemble life-saving equipment in a timely fashion, whom should you call and let know?
