White Coke Cans and the Importance of Visual Cues in Reducing Medical Errors

I read with some amused interest that many consumers were upset that Coca Cola had updated their traditional red regular Coke can for a holiday themed one complete with white packaging. The new holiday design was felt to be too similar to the diet Coke, which is silver. Although Coke has released festive appearing Coke cans in the past, this design was devoid of significant elements of red which make it stand out from the silver Diet Coke packaging. This year Coke felt a bold design would highlight their association with the World Wild Fund and saving the polar bear.

As a result, Diet Coke drinkers not realizing the switch would find themselves gulping the sugary regular Coke, an absolute no-no.  Outraged, they took their concerns up on the internet. Coke has decided to take the new white Coke can off the market and replace it with the traditional red Coke can sooner than planned.





But what does this have to do with medical errors?

Plenty.

Doctors and nurses often work in a world devoid of visual cues where the stakes are much higher than sipping the wrong type of cola. Ironically, doctors and nurses when they makes these errors, they blame themselves and not the package design for some of the error. Even the public

Case in point?

About four years ago, actor Dennis Quaid's newborn twins nearly died from a drug overdose of the blood thinner heparin while hospitalized at the prestigious Cedars Sinai medical center.  The babies were given the adult dosage of heparin which was 1000 times greater than that for a baby. Their blood essentially was water and coming out of every orifice.

Part of the reason for the error? The packaging of the vials for adult and pediatric heparin is nearly identical.





Do they look identical to you? A busy nurse used to routine perhaps gets a heparin dose which by design looks similar but not exactly the same mistakenly draws up the dose because it looks similar but not difference enough to jostle her conscious memory that there is a problem here. This is part of human nature and using mental shortcuts subconsciously. Looking at it now with your full attention it seems obvious.
 Even the public and health care personnel often attributed the error to the individual rather than the design packaging when reviewing some of the public comments related to the story.

Why is Baxter being sued for the hospital having stupid nurses who can’t read?… Shame on Dennis Quaid and shame on the Cedars Sinai for retaining a moron of a nurse.

As a nurse, the reality is that the NURSE DID NOT READ THE LABEL before admninstering the drug. Nurse are taught to take a minute and look over the drug that are about to give. Is it the right route, the right dose, the right drug and is it the right patient. We are taught to not check one but twice or three times. Besides heparin there are many different drugs pachaged the same way. You would have to change every single drug packaging to prevent errors. The reality is the nurse DID NOT perform the 4 checks she was suppose to! That is not the fault of the pharmaceutical company.

But in an intensive care unit where you normally work everyday and where you never had had an error and you mistakenly draw up a medication 1000 times too potent because the packaging looked similar enough that your brain didn't see a problem? You didn't realize that somehow the high dosed medication made it to your hand.

Kind of the same way many diet Coke drinkers didn't realize a higher calorie content soda reached their hand and in their mouth as they went about their routine daily lives.

Unlike doctors and nurses, however, the public rightly didn't blame themselves. The package design contributed to their error.  It is about time that our health care providers do the same and work on fixing the system we work in rather that often simply concluding it is the fault of the individual.

As for me, I think I'll pick up some white Coke cans for the holidays. They are kind of cute!

Your Medical Mind - Book Review. Best for Patients or Doctors?

I looked forward to reading Dr. Jerome Groopman’s new book, Your Medical Mind: How to Decide What Is Right for You , co-authored with Dr. Pamela Hartzband.  His previous work, How Doctors Think , shaped my thinking as a practicing primary care doctor on the importance of language and the potential pitfalls we make in reaching decisions.  I always recommend my medical students read that book.

Unfortunately, his latest work fell quite short of my expectations.  In it, the authors try to understand and create a framework on how patients reach decisions about their medical care.   In the end, this was a book about human psychology wrapped in the doctor patient relationship.  Nothing particularly earth shattering here.

The real question I had is who is responsible for helping patients avoid these cognitive and psychological errors?  Patients or doctors?

They note how the mindset of patients can be divided into the following categories – “believers and doubters; maximalists and minimalists; a naturalism orientation or a technology orientation.”  Specifically, some patients want maximal treatment and others believe “less is more”.  To avoid cognitive traps, the authors recommend that data be viewed in both positive and negative forms.  Telling a patient that a therapy has side effects for 10 percent of patients is very different than saying 90 percent of patients have no side effects.

Other tips to good decision-making included minimizing emotion before deciding, bringing a friend or family member to an appointment to provide additional eyes and ears, and also getting second opinions.  Finding a doctor who provides “shared medical decision making” might also decrease the chance of making a choice only to regret it later.  In the book, many patients moved beyond decision paralysis upon hearing a story of another patient with a similar illness and predicament.  Specifically, patients realized that instead of focusing on the negative, like the side effects, focusing on the positives and the ability to adapt made all the difference.  There is both power and potential pitfall in hearing other patient’s stories, which may be anecdotal.

Dr. Groopman and Dr. Hartzband noted that patient decision making and autonomy vary depending on circumstance.  Sometimes patients want full control.  Other times they wish to cede it to physicians, hence the reason many want to find the “best” physician.  Surrogates, who act on behalf of patients when incapacitated, are ideally supposed to use “substituted judgment” and choose treatment based on what the patient would have wanted.  Like patients, however, surrogates too will change their mind or relinquish or reclaim autonomy depending on the situation.  As a result, sometimes doctors use the principles of “beneficence”, the principle that physicians should act in the patient’s best interest, and “nonmaleficence”, to do no harm.

Physicians can also unwittingly bias a patient’s decision by recommending a “best” treatment and downplaying others, which could be a better match for the patient’s preference.  Although there is a movement in health care to provide treatment which is evidence based, the authors conjecture that this focus would result in doctors recommending treatment not in preference of a patient.  These seems rather ludicrous as already many current guidelines are not being followed.

The authors conclude that patients are best served if they find doctors who do not superimpose their preferences while at the same time don’t simply rubberstamp what you want.  “A doctor who facilitates but also may challenge your decision process sometimes gives you more.”

Completely agree. Perhaps this book is best suited for doctors.  While the book may be an enlightening read for patients, there isn’t necessarily an easy practical framework which will help them make the right decisions.