The birth control pill recall, and industrial design

[elfs]

I read today about a recall of birth control pills. The detail that caught my attention was this:

Blister packs of the birth control pills were rotated 180 degrees, which reverses the weekly tablet distribution. This packaging error could cause women to take pills in the incorrect order and could lead to unintended pregnancy.

I suspect this means someone at the factory put the empty blister packs into the packaging machine upside down.

Buddha wept, this is Industrial Design 101. If you have an integration process where orientation is important, you avoid this kind of disaster by enforcing orientation through asymmetry. You can't plug a USB cable in upside down because the plug is asymmetrical along the critical axis. You shouldn't be able to load unlabeled blister packs into a machine upside down, nor should it be possible to fill and label those blister packs. All it would take is a notch in one corner to ensure orientation.

I'm sure press people would assure me "it's more complicated than that." No, it's not. I could be wrong about the mechanical particulars, but issues like this represent a systems design error of a real-world artifact: somewhere along the way a physical template, die, guide, measure, or clamp that could have been designed to prevent this from happening was not.

Comments

[resonant.livejournal.com]

Agreed - nearly every manufacturing facility in existance has whole-heartedly embraced the concept of Poka Yoke. There are excellent reference books with tens of thousands of examples, for every concievable assembly operation.

In addition, computer-based vision systems are incredibly cheap these days. It costs very little to provide automated visual inspection of 100% of product, with automated checks for size, shape, discolouration, cracking, orientation, and even OCR of markings. If there was any visible difference between the different pills, a vision system would have flagged the error before product left the packaging facility.

https://secure.wikimedia.org/wikipedia/en/wiki/Poka-yoke

[moiety-tx.livejournal.com]

Based on the names, though, this might have been one of the varieties where each of the 3 weeks of active pills are also a different color (and different strength, etc) making it fairly non-obvious which ones are really the place holders.

I agree with Elf, this was probably human error allowed for by poor design decisions.

[urox.livejournal.com]

The 2 sets I've used have both had the off week as brown because they had iron supplement in them.

[doodlesthegreat.livejournal.com]

Equally important: The Design of Everyday Things by Donald Norman. This book should be on every industrial designers shelf, preferably at work and at home.

[rhonan.livejournal.com]

The notch on old-school dog tags was there to make it so that the tags could only go into the stamping machine the right way.

[fayanora.livejournal.com]

Amen.

Though I will say, USB ports annoy me. If I can't see the side with the symbol on it, it takes me half a dozen or more tries to get the thing into the port.

[maskwa.livejournal.com]

If a pressman says "it's more complicated than that" then they *must* be splitting hairs. It is as simple as it seems.

A related failure mode may be that - even if the blister packs are 'keyed' - the machine that holds the dies and the dies themselves may not be. A maintenance job may have put a catcher in backwards. Still, it's the same damn thing - key it!

Complicated is PR for "They're cheap SOBs."

[pakraticus.livejournal.com]

It's not keyed because they want to save money using the same machine as anything else that comes in a 28 pill blister pack uses.
And they are the same color because they don't want to pay for a different coloring agent.
Color me surprised that they don't opt to ship 21 pills and the instructions "Take one pill a day starting at next full moon." I mean it worked for India.