I was startled from my half-asleep state early this morning by a news story on CBC Radio about a patient fatality resulting from an overdose of medicine administered through my home institution, the Cross Cancer Institute. I won’t make any specific comments about this case, leaving that to the CCI’s Communications Office because I have no professional connection to the events and know only the facts made available to the media.

But I will wonder about how the design of the medicine administration system allowed such an error to occur. Analysis should include all aspects of the process, including the delivery mechanism, a programmable pump. At an informatics conference I attended in 2004, we learned that usability simulations at the Centre for Global eHealth Innovation http://www.ehealthinnovation.org/ have found that some kinds of pumps are, because of their interface design, accidents waiting to happen. Mandating one, two, even three human checks is one after-market way to deal with this, but does not address the root cause. Pump manufacturers should be held to higher premarket standards of design safety.