| About 15 years ago I worked for a medical usability firm. We did a review of the Baxter Large Volume Infusion Pump. Among dozens of other issues[1] we found, the absolute mother of them all was the stop button, which had been overloaded to have multiple functionalities: If you push the button once, it would stop infusing drug into the patient. If you push the button twice, it would EMPTY THE SYSTEM - as in, run the pump continuously, infusing all remaining drug into the system, at high speed. We ran usability tests where we'd say to the nurse "wrong drug! stop! you're giving the patient the wrong drug!" 90+ percent of them did what any human would do - jab STOP over and over. Whoops, patient's dead. In part because of our report Baxter was forced to recall[0] hundreds of thousands of the pumps and pay for their replacements with competitors' products. The stock dropped by 30% in a day. Sadly I didn't short it, or I'd be [checks notes] in jail. [0] https://archive.is/s1wEU [1] like drug libraries where sometimes the units were displayed, sometimes they weren't, and sometimes they were displayed in your "preferred" units even though the number being shown was in a DIFFERENT unit and the system didn't translate it, just showed the wrong value. |
Wow this sounds so dangerous and so easy to predict.