I was just thinking, "Well, doctors would probably catch a dosage error 
that's a thousand times greater than what they expect."

THEN I thought, "Yes -- they might, but what about an automated system 
that's had the incorrect values ported into it to begin with?"

A few years ago, a notorious and tragic medical mistake occurred in 
Boston. The health reporter for the Boston Globe, a beautiful young 
woman with young children, no less, was treated for breast cancer. She 
was erroneously given massive doses of one of her chemotherapy drugs, 
and no one caught the error. It killed her.

The Globe pursued the story mercilessly. One of the resulting 
"improvements" to medical practice was a system that would automatically 
double-check every dosage prescribed for patients. "Oh, yes," I thought 
at the time, "this will certainly catch situations in which a doctor's 
handwriting is illegible and the nurse misreads it, or somebody is 
simply asleep at the switch and scribbbles down the wrong thing .. . "

Well, yeah, but what if the data ported into the wonderful new automated 
system is wrong to being with? Who will guard the guards?

Just don't get sick.


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