Download a free copy of “The New Design Fundamentals,” a curated collection of chapters from the O’Reilly Design library. Editor’s note: this post is an excerpt from “Tragic Design,” by Jonathan Shariat, which is included in the collection.
I love people.
I love technology and I love design, and I love the power they have to help people.
That is why when I learned they had cost a young girl her life, it hurt me deeply and I couldn’t stop thinking about it for weeks.
My wife, a nursing student, was sharing with her teacher how passionate I am about technology in health care. Her teacher rebutted, saying she thought we needed less technology in health care and shared a story that caused her to feel so strongly that way.
This is the story that inspired me to write this book and I would like to share it with you.
Jenny, as we will call her to protect the patient’s identity, was a young girl who was diagnosed with cancer. She was in and out of the hospital for a number of years and was finally discharged. A while later she relapsed and returned to be given a very strong chemo treating medicine. This medicine is so strong and so toxic that it requires pre-hydration and post-hydration for three days with I.V. fluid.
However, after the medicine was administered, the nurses who were attending to the charting software, entering in everything required of them and making the appropriate orders, missed a very critical piece of information: Jenny was supposed to be given three days of I.V. hydration post treatment. The experienced nurses made this critical error because they were too distracted trying to figure out the software they were using.
When the morning nurse came in the next day, they saw that Jenny had died of toxicity and dehydration. All because these very seasoned nurses were preoccupied trying to figure out this interface (figure 1-1).
Figure 1-1: This is the software that was used at the hospital for many years.
When I heard this my heart sank and when I looked up screenshots online of the tool they used (which my wife who worked at the same hospital confirmed still looked that way), I was furious! How could such a critical service in our lives be employing such terrible software? Now, some would argue that the fault lies with the nurses; I would disagree and I’ll address this later on, but regardless, that discussion would be missing the real point, one which we all need to consider.
So, let’s stop and ask ourselves some very important questions, ones that don’t get asked enough in Silicon Valley, where I’m from:
“What is the purpose of technology?”
“Why is design important?”
“How will what we are making, and how we make it, affect the world?”
I’ve been designing interfaces for almost a decade now. Like many of my peers, I started hobbling together websites and photoshopping posters until I found my way to designing interfaces and delving into user experience design. All the while, the industry has exploded and design has matured into the leading differentiator. I admit that I, too, have gotten caught up in these billion dollar exits and the glamour of tech. I started out wanting to make the world a better place, but I soon found myself blindly building technology that was chasing dollars and not outcomes for real people, not just “users.”
“What is the purpose of technology?”
This is such an important question everyone involved in building technology should seriously ask themselves, ponder, and write down their own answer to. Frankly, I’m embarrassed that it has taken me this long to answer it for myself because I know that if you want to be great at something, you have to fundamentally know its purpose. Many of the great designers, engineers, and entrepreneurs who we look up to have done this at some point on their journey, and you should, too, but let me give you my own definition — and to be completely transparent, my failed attempts as well.
The purpose of technology is to help people do more. (“More” is too ambiguous and does not give us direction on why “more” is good.)
The purpose of technology is to extend what is possible. (Just because something is possible, doesn’t mean it’s something we should do.)
The purpose of technology is to benefit humanity. (Close, but it doesn’t always have to be so serious; technology can just be fun.)
The purpose of technology is to increase the quality of life. (For whom? Sometimes we must sacrifice an increase for us, if it hurts someone else.)
The purpose of technology is to serve our needs, for the benefit of all.
That is the definition I was most happy with, the one I felt encapsulated all the important parts of design that are relevant to me. Technology should serve needs, big or small. It should do it in an inclusive and constructive way that benefits everyone.
“Why is design important?”
So, how does design fit into technology? Design, as Jared Spool so succinctly put it is “the rendering of intent.” While that is a very correct, logical, and succinct way of boiling it down, I feel it misses one important element: people. Of course, there are cases where something can be “designed” that has nothing to do with people, but I would argue that that falls closer to “engineering” — but alas, that is the frustrating obstacle of language. I would define design, especially in the sense of designing products and software, as “the planning of technology’s relationship and interaction with people.” The definition of design simply has to include people. Bad designs are always the ones that collide with human behaviors; therefore, good designs are the ones that are transparent and helpful.
When we create things without the end user in mind, or with some vague sense of them as a customer, we almost always end up creating a bad design. I like to call this an “undesigned” product. These undesigned products serve their creator first and the user second. When we create like this, it produces bad design, and bad design, like this book will convey, produces real harm to the people who experience it. Good design attempts to understand the intended user and create an experience that serves their needs. A good design is worthwhile one. One whose existence isn’t a burden on its users but instead makes their life better in some way.
However, good design isn’t just a bunch of goodwill and pleasant feelings; it’s good business, too. Designing well creates worthwhile experiences, and that sells. If your product serves you and your competitor’s product serves the customer, then the customer is going to use the one that was made for them first. In today’s technology landscape, it’s easier than ever for competitors to match features and scale up to millions of users. Thus, user-centered design, because of its accessible nature, will become the main differentiator.
Technology meant to be used by people but created without their needs first is not moving forward; it’s moving back. Design is important for this reason: it is the bridge between what we want technology to do and having it benefit everyone. It acts as the interface between technology and the people it’s supposed to be benefiting. When that bridge isn’t there, the opposite happens, and it’s destructive. It sets technology back; it sets us all back.
“How will what we are making, and how we make it, affect the world?”
So often those of us passionate about technology get caught up in the science and exploration of it. We gawk over what is possible with it and rarely stop to think about the “why” of it. We who dream and create are the gatekeepers of the imaginary world into reality. We are responsible for what we bring into this world. In the same way that a parent is responsible for their child. Yet, we often create at a whim, chasing the next idea, the next dollar, the next trend. Asking this question is not only important from a philosophical or moral standpoint, but this has business implications as well.
Asking this question reveals if you have any effect at all. Furthermore, how we create that thing is also highly important. We must ask ourselves: is our success coming at a hidden cost? For some companies, that might be the environment; for many, though, that cost is their own employees’ wellbeing. In a company, employees should come before customers. Because you can’t please a customer with unhappy and uninspired employees. It’s like trying to paddle up river with a whisk; your employees are your tools to making things happen and are worth caring for.
Now that we have answered those three important questions, let’s take a fresh look at Jenny’s story with this added context. What were the factors that lead to her death? What was the purpose of technology in Jenny’s story? How was design important? How did the software, and how it was made, affect her life?
Health care right now is facing a crisis. In 1999, a landmark report concluded that 44,000 to 98,000 people a year die from medical errors at a cost of 17-29 Billion per year. A more recent study done in 2014 puts the estimates of 100,000-400,000 deaths per year. Like the recent study says: “In a sense, it does not matter whether the deaths of 100,000, 200,000 or 400,000 Americans each year are associated with PAE [Preventable Adverse Effects] in hospitals. Any of these estimates demand assertive action.”
Jenny’s story is, unfortunately, not uncommon. When we blame the nurses, we miss the entire context that leads up to that grave mistake. In nursing, they call it the “swiss cheese model.” There are multiple layers before a mistake can get through to affecting the patient. For example, when there is a medication error, an error can occur at any of these “layers”: the doctor’s prescription, the pharmacist filling it, the medication getting stocked correctly and in the right dosage, the nurse preparing and giving it, and the mechanism of delivery. Each layer will have its own holes, but together they make the chances of the error happening very rare. Nurses are the last line of defense in that chain, so it’s easy to blame them for many of the mistakes that can happen.
Design is the interface between people and technology.
In the case of Jenny, the software was taking up their cognitive capacity, which was loaded with having to figure out how to use the interface to chart the patient’s care and make the appropriate orders. The nurses weren’t negligent; they were human. They were working in an environment that was working against them. Try to imagine if you were required to play a difficult game on your phone while you drove — how many mistakes would you make over the course of a year? Up to 400,000 people die from medical errors a year. Blaming the nurses is to completely miss the root cause. The system is broken, and design should be the way forward in repairing it. Technology in health care should be used as a tool to ensure mistakes don’t happen. In the case of Jenny, it was a factor in the cause of a tragic error.
That’s the crux of it all. Design is the interface between people and technology. Without good design, the technology is turned from a help to a harm. It can cause physical harm, like in the case of Jenny. It can cause emotional harm, like when a social app facilitates bullying. It can cause exclusion, like when a seeing-impaired person doesn’t get to participate on a popular website because simple accessibility items have not been attended to. Lastly, it can cause injustice — yes injustice — which all of these can be categorized under, but direct injustices like nullifying someone’s vote or someone in need who isn’t able to access help to get back on their feet.
The scary thing is that, right now, our world is full of bad design and it’s costing us dearly. It’s costing us lives, time, money, joy, and justice. It’s scary because I never thought design would play such an important, weighty role in the world, but it does. We are the gatekeepers; it’s up to us to make sure the gates are as wide and easy to cross as possible. We need to provide people with proper access, interaction, and use of technology so it serves their needs and doesn’t work against them.
In the following chapters, we will dig deep into specific stories of how bad design interferes with people’s lives in very real ways. We will explore extreme examples as well as more common ones that will surely affect you in your career. While this book will be filled with practical advice about how we can tackle these difficult issues, my main goal is to shed light on these areas, to illuminate your mind to how bad design affects peoples lives. That’s the most important step to solving any big problem in life: illuminating it. Once we have the bigger picture, we will talk about how we can fix it — designers, makers, all of us. Together.