LEARNING FROM MISTAKES. PATIENT CENTRIC DESIGN EDUCATION EXPERIENCE

V.M. Iannilli, A.V. Penati, C.E. Standoli

Politecnico di Milano (ITALY)
Rough, systematic and random errors unravel along the relationship path between the user and the medication-product. A relationship that lasts the "time" of care and that sees the user as interpreter of different roles and situations. It is the care for oneself, but also one in which the role is to assist someone else. An experience that moves along a path that goes from prescription to dispensation and finally to effective treatment: three fundamental moments in which different actors, often unrelated to each other, could contribute to the propagation of the error, but not only. Doctors, nurses, pharmacists, sick people, relatives, carers, interface themselves with names, boxes, openings/closures, graphics, instructions, shapes, colors, recipes, words, pills, capsules, syrups, vials, and then weights, measures, doses, half doses, quarter doses, in an experience in which precision and imprecision seem to be the sides of the same coin. The problems of clarity of "understanding" between medication object and user are complex and refer to logical-spatial correlations between what one wants to do (or make do) and what appears feasible. If the most obvious (and most investigated) error is often connected with the communicative-functional practices of packaging, the risk is to lose sight of other sets of practices on which so many possible "errors" depend. The work presented is part of the basic research Care for Care! Shaping Medication: Question of Identity, Use and Communication (FARB Project, Design dept./Politecnico di Milano). Starting from the consideration that a significant percentage of errors and/or difficulties in taking pharmacological therapies derives from info-communicative deficiencies, from the lack of identifying signs and from the inadequate design attention to "medication" product, the research proposes a design-oriented approach to the pharmaceutical product system. Design is framed as a necessary discipline because it is capable of a broad meta-project vision where medicine is part of a broader context of use, function and experience. A design vision in which the centrality of the user becomes a guiding element in order to foster a different interpretation of the medicine-product. The recognition of knowledge as a context characterized by a systemic and non-linear process - in which precisely its fallibility represents the possibility of improvement and progress - leads design to assume the error and its mapping, as a starting point to trigger new trajectories for the improvement of the product-pharmaceutical design. The article highlights a particular way of learning that takes place in the use of objects, which does not point out best practices but focuses on errors, improper uses, abuses, misunderstandings as a basis to train sensitivity and refine attention on the issue of interaction between person and object.