Comment by notzane

The High Velocity Edge had a lot about this subject.

The most memorable example was at a hospital, nurses would occasionally pick up the wrong vial. They always noticed before injecting, but there were lots of close calls that didn’t get tracked anywhere. Once they started tracking that as a leading indicator, it became pretty obvious that the vials needed a better design to prevent even the possibility of grabbing the wrong one. Also, if the hospital never realized this problem and someone got hurt, they would’ve ended up with a much worse solution like “double check really close”