Nudge

The nozzles that deliver diesel fuel are too large to fit into the opening on cars that use gasoline, so it is not possible to make the mistake of putting diesel fuel in your gasoline-powered car (though it is still possible to make the opposite mistake). The same principle has been used to reduce the number of errors involving anesthesia. One study found that human error (rather than equipment failure) caused 82 percent of the “critical incidents.” A common error was that the hose for one drug was hooked up to the wrong delivery port, so the patient received the wrong drug. This problem was solved by designing the equipment so that the gas nozzles and connectors were different for each drug. It became physically impossible to make this previously frequent mistake.3