In addition to the human element, regulators reviewing the cases cite the lack of sanity checks embedded into the pump as an issue that needs to be addressed. Yet another example of technology designed without proper validation testing to account for human error.
The nurses involved in most of these cases are not being disciplined. Regulators cite systematic failures that should have been addressed when the procedures and technology were implemented.
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Thus spake the master programmer:
"When a program is being tested, it is too late to make design changes."
-- Geoffrey James, "The Tao of Programming"