The stuff should be shipped with a certain amount of food coloring proportional to the amount active ingredient. The kids’ version would be visibly different from the adults’, and whether you’d mixed it wrong or grabbed the wrong bottle by mistake, you’d know.

Does this sound at all practical? Is it a technique that’s ever been used elsewhere?

Thank you Mark for your insight on this. Your concept of finding the “root error” hit’s home with me. I work with customer returns and I see the human errors that are made. At my company we have many inspection operations throughout the process. We manufacture parts for airplanes…

Here, maybe they only buy one dose and then dilute it for children’s use? That seems really risky and penny-wise, pound-foolish (but again, I’m speculating).

As I’ve blogged about (and write about in my book), hospitals are too quick to blame individuals instead of looking at process.

To be fair, the people who caused the error probably do feel terrible. It might truly be voluntary leave… many people leave healthcare because they’re devastated an error occurred. But the hospitals are often also quick to suspend or fire people, which isn’t getting to the root cause at all. Sad.