What's wrong with this picture? - XV Don't mess with success!

Hi! Long time, no see.

Thanks to Mark Wahba's keen eye for this one:




Bright yellow "Sharps" containers are ubiquitous in health care facilities. Pointy, pokey stuff goes in them after it's been used. This reduces the chance of needle-stick injuries. While the containers come in different shapes and sizes, their uniform yellow color is a strong visual cue as to their presence and purpose.

However, someone tried to "re-purpose" this large sharps container for something else. They had relabeled the contained, but that label didn't last long. Even if it were now being used for regular garbage, it's still unsafe because the staff emptying the garbage wouldn't be expecting uncovered needles in the container.

Surely, you say, a person would stop and think before dropping sharps into this container. After all, there are clues that it isn't a real sharps container: it's sitting on the floor, there's no safety top to prevent people's hands from rooting around inside.

You'd be wrong. Mark mentioned that he had dropped one sharp into it already. And why wouldn't he... the containers give a (supposedly) unique visual cue.

The best part of this story is that Mark pointed (sorry...) out the problem to the department manager, and the practice was stopped!

Here's another example of someone messing with visual cues:



Clean isolation gowns used to be folded and stacked on carts outside a patient's room. You would put one on, enter the room to perform care, and then discard the dirty gown into a laundry hamper outside the room.

Then, someone had the idea of leaving the gowns unfolded, in large plastic linen bags. I'm sure that saves a lot of time by cutting out the folding process. Unfortunately, the "clean" plastic linen bag with rumpled gowns in the bottom of it just screams "Put your dirty laundry in here!" Once a dirty gown has been dropped in, the entire bag is contaminated, and has to be laundered again. Or, worse, the wayward gown is not recognized and then is a source for cross-contamination for another patient.

I've made the mistake myself.

Someone has recognized that it's a problem and tried to remedy it with a hand-lettered sign on the bag. Nice try, but the sign presumes that the person about to dump their dirty gown into the bag is approaching it from the side the sign is on. Also, it presumes that they can read English.

We get clear and important information from standardized visual cues: Skull and crossbones on a plastic bottle - Poison!, Red light - Stop! They prompt us to act, or prevent us from harmful action, in critical situations, without the need for deliberation. Don't ignore people's mental inertia when redesigning the system.

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