Hmm.... that sounds familiar... That said, I'm not sure why it takes three days to say "because the nurse didn't think there was anything funny about giving an 8-year-old 39 pills at once."Heeding this feedback, the medical center chose to disable thousands of the alerts built into the drug database system that the hospital had purchased along with Epic. Despite this decision, there were still tons of alerts. Of roughly 350,000 medication orders per month, pharmacists were receiving pop-up alerts on nearly half of them. Yes, you read that right: nearly half. The physicians were alerted less frequently — in the course of a month, they received only 17,000 alerts.
The mechanical failures were compounded by the initial failure of plant operators to recognize the situation as a loss-of-coolant accident due to inadequate training and human factors, such as human-computer interaction design oversights relating to ambiguous control room indicators in the power plant's user interface. In particular, a hidden indicator light led to an operator manually overriding the automatic emergency cooling system of the reactor because the operator mistakenly believed that there was too much coolant water present in the reactor and causing the steam pressure release.