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The Miraculous Tableware Sparkler: A Lesson in Human Factors

By Caitlin Littlefield | Wednesday, October 23, 2013

THE PROBLEM [Internal email to ALL IHI from Alan Olasin, AV Technician/Facility Manager]


Beetlejuice Beetlejuice Beetlejuice.

Did that work? No? Darn.

I was hoping he would show up and make the soap-sud disaster upstairs turn into mini marshmallow monsters as that would be easier to catch and clean up (not to mention ADORABLE).
What am I talking about?





Someone put “dish detergent” into the dishwasher. Sadly this creates a LARGE mess that Jameson helped me clean up. Thanks Jameson. The “Dish Detergent” is for manually washing your dishes and this should NEVER go in the dishwasher. This could have been avoided if Josephine Cochrane named her invention “the miraculous tableware sparkler." But alas we have two similar bottles, with similar names, that basically do the same thing. The picture below is bad but the one on the left is “Automatic Dishwasher Gel." That is what you use in the dishwasher. It resides in the cabinet under the left microwave. The one on the right is “Dish Liquid” and it is for the sink that it lives next to.




Thank you for running the dishwasher but please make sure you use the right ooze.


RESPONSE #1: [Email response from Carol Haraden, PhD, IHI Patient Safety Expert Faculty]

Poor human factor design strikes again: look-alike, sound-alike problem. Happens with medications all the time!

Sadly, reminding people to use the right one does not work.  People are talking, running from one thing to the next and generally distracted and will always pick the wrong one at least 3 out of 1000 times (errors of commission).  Here is a test we could run:

#1. Put a picture of a dishwasher on the correct soap bottle and a ‘STOP – THIS IS FOR WASHING BY HAND’ sign on bottle.


Much more likely to succeed over time.

Thanks, Alan and Jameson, for the help and the great human factors lesson!


RESPONSE #2: [Email reponse from Chris Hayes, Medical Director, Quality & Patient Safety]
The downstairs dishwasher doesn't need/use detergent...an example of engineering the problem away.


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