The Designer/Programmer

• As a computer professional, you are most likely going to be both the designer and programmer of a system.

• Poor design results in non-use, mis-use, abuse, and (potentially severe) errors.

• Case of the Tell-Tale Heart:

Slide Comments:

Case of the Tell-Tale Heart:

This is a personal encounter with a bad design that almost resulted in a person’s death.

When I was a practicing nurse I worked on a Cardiac Care Unit. In this unit each patient received a heart monitor that was connected to a wireless radio transmitter so that each patient’s heart rhythm can be seen at a central desk. One night shortly after coming on shift I noticed that one of the patients went into a potentially serious heart rhythm, which left untreated could result in death. The main treatment for this person’s condition is to implant a pace maker until medications can take effect. After calling the patient’s doctor and making arrangements with the Operating Room I talked to the patient to get a consent for surgery. The patient who was reasonably upset refused saying she felt fine. It is not unusual for the heart to compensate for rhythm problems so the lack of symptoms was not unusual. After trying to convince the patient for sometime we called her husband and doctor to come in. Three hours later she finally consented.

As they wheeled her into the elevator, to my horror, her heart rhythm from the wireless radio remote did not fade from the screen, but another patient’s did! I quickly called the Operating Room to notify them they had the wrong patient.

What had happened was the result of a bad system design. In this case, the only way to distinguish one patient from another on the heart monitor was by a piece of masking tape with the patient’s room and bed number on it. By accident two pieces of tape were transposed. As a result, the wrong person almost had surgery and the other patient could have died because of lack of treatment.

A better design for this system would allow for a patient’s name and room to be input to the system so that a heart rhythm and patent can be directly associated.