I must confess: I had just about zero interest in the story of the chemo overdose.
I happen to work in a human factors laboratory. No, I don't design medical devices (despite having originally trained as a biomedical engineer).
Labelling the pump that dispenses in ml/hr in a different color from the pump that dispenses in ml/day would be an obvious remedy that would have addressed the KK incident. It's the common-sensical solution that anyone can think of.
Ah, but if you were an actual human factors professional, I can assure you that things would not be as simple as that.
Sometimes, design flaws like that really do occur because engineers can't see the wood for the trees. It never occurs to them that someone handling the pumps might actually make a mistake that could result in fatal consequences. That's when having a human factors professional as a member of the design team helps: by explicitly designating a person to consider human-centric issues.
But sometimes the team is aware of these issues and highlights them to management, but the manufacturer still proceeds as before. Why is that? Because in addition to design principles, one must be mindful that there are always business considerations at play as well. Manufacturing two (or more) separate designs for pumps incurs greater costs, eliminates the ability to standardize across pumps, increases holding inventory, and overall increases complexity of business and manufacturing processes, and decreases economies of scale. All this naturally reduces profitability.
It's not just pumps. Even medicines are typically sold in identical-looking vials with identically colored vial caps, with only the text on the vial labels differentiating them in both drug type and concentration. You can imagine what kinds of accidents can potentially happen there.
The point is, in both these cases, business considerations override human factors. Legally, the manufacturer has clearly labelled on the pump (in text) the appropriate dosing regime, or for a medicine vial, the type of drug and concentration. The manufacturer has hence fulfilled its duty. Therefore, if there are any mistakes in dosing, the liability for the error lies with the hospital and not the manufacturer of the product. The victim of such a dosing error can be said to be an "externalized cost"; the beneficiaries of the victim's suffering are the manufacturer, who enjoys greater profitability, the hospital, which enjoys greater cost-savings, and the public, who save on healthcare.
Is it ethical of the manufacturer, to "pass on" liability to the hospital? To make it difficult (or at least not easy) for the hospital to administer the right dosage? Maybe the manufacturer is at fault, but IMHO, it's very hard to say. The reason why I am so ambivalent is because I am able to see the big picture.
If you were the administrator of a public hospital, charged with keeping healthcare costs low, and you had a choice between more expensive but better designed equipment, and less expensive but poorly designed equipment which nonetheless gets the job done, which would you choose to purchase?
The pressure to keep costs low is immediate and apparent, but the fallout from a medical error only comes when an error does happen. Not to mention errors by nature rarely occur, and it's not like well-designed equipment eliminates errors; they only reduce the probability of occurrence.
Given this reasoning, a typical hospital administrator would probably (and not unthinkingly) choose the most cost-effective product that gets the job done. Repeat this scenario across the whole hospital sector and manufacturers that produce the better designed product simply cannot compete. So all manufacturers end up making the generic, not very well-designed product, and of course, it makes perfect business sense to do so, seeing as how manufacturers can reap the economies of scale.
And that's how we end up in the current situation.
When a chemo incident like the one that happened in KK occurs, there are cries of public remonstration, and the pendulum may swing the other way. Hospitals might make the decision to purchase more expensive and better designed pumps (that is, if they are available). Then years down the road, when a bureaucrat (or a management consultant) with an eye to trim costs looks through the hospital purchasing orders, they may make the suggestion that $XXX could be saved by buying the generic version of such-and-such a product, instead of the more expensive version. And they would not be wrong, just...myopic.
Then the cycle starts again.
Sometimes it's not only about human factors. It could be about policy, or human nature, or business fundamentals, or just the plain old, dysfunctional way the world works.