Abstract
Our forensic human factors firm was retained to research the facts and formulate an opinion about a series of errors that resulted in an incorrect intravenous bag being used on a hospitalized patient. The patient died as a result of the administration of this drug. We were asked to explore the issue of errors made in administering medications and to provide an opinion specifically regarding the labeling of the subject intravenous bag product. In the process of exploring those issues, we also assessed the frequency of this type of error involving product labeling and packaging of drugs and why these errors are made by trained professionals. From our research into medical error statistics, theories of human error, and design principles for product labels, we provided recommendations for improving the labeling and packaging which, if implemented, would most likely help to reduce these types of errors.
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