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Examples of the kinds of problem our research is investigating

Here is an illustrative example of the kind of real world problem our research will address: a nurse had a problem in using what seemed to be a familiar syringe pump to deliver medication…

A nurse who was familiar with syringe pump A was using the similar syringe pump B from the same manufacturer. On pump A pressing the units button enough times causes it to cycle into the tens (...8,9,10). The nurse expected pressing the units button on pump B to have the same effect. It did not. Instead it cycled around the unit values (...8,9,0), resulting in an incorrect dosage being delivered to the patient.

Many factors contributed to this incident. For example, the two pumps look similar, with similar buttons for entering data. Neither alerts the user to differing effects when buttons are pressed more than nine times: both beep in an identical way. The nurse may not have been trained on the differences between the models, or may have been distracted and performed data entry as if working with pump A.

See also our examples of stories about patient safety in the news.