The Color Changing Card Trick

Originally posted 7-1-2010:
I'm going to have a little fun with this post.  This card trick video was presented in the Safety and Quality in the Medication Use System course I took last year.  Don't read ahead until you watch it:

Did you catch all four of the color changes?  If you did, then you have an astounding attention to detail.  The first time I saw this I missed every one of the real "tricks" in the video.  I think I was just a little too focused on that 3 of diamonds.

So why would I show this?  First, I think it's fun and hopefully you thought so too.  More importantly, I find this video a great example of how easy it is to miss the "obvious".  With so much focus on the cards, the other changes in the video get lost.  It illustrates how easy it is for human error to occur.

Now imagine this sort of scenario happening in the healthcare setting.  The healthcare environment contains so much important patient related information in a background filled with distractions.  Something as simple as transposing numbers on a date can be potentially dangerous.  A pharmacist friend of mine told me a story where they wrote up a drug intervention based on a lab result from June 4th.  They came to find out later that the result was actually from April 6th and the intervention was unnecessary.  They read 6/4 when it actually was showing 4/6. (Cognitive psychologists call this bias.) Luckily, the patient wasn't harmed as a result.

A good system around the clinician will catch these sort of errors before they can reach the patient.  In this case, a simple system change could be writing out the months on lab report dates instead of using the numbers.