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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 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.