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!