The Yellow Stickie Ain’t Dead Yet

I had to go into my hospital last week to get an intravenous infusion to help me with the effects of a neuropathy. The receiving desk at the IV Infusion Center had three computer monitors with two people sitting at them. My physician’s orders were already printed out and were attached to my computer printout encounter form. After receiving my computer generated ID bracelet with bar code, I was lead into a room with four chairs, each one next to a computerized infusion pump with blinking lights and various sounds to convey different messages to the nurses caring for me. Each pump had touch-screen data entry and a multiple color display combined, was capable of at least three distinct alert sounds, and was neatly packaged to fit on a standard IV pole. The combination of four such poles, two automatic blood pressure machines with their display screens and alert sounds, the usual wall of oxygen, suction, electrical outlets, and signal lights, a R2D2-size mobile air conditioning unit standing in the middle of the floor with its coiled, white PVC exhaust duct winding to the wall, and four brand new baby blue Barca Loungers made me think that this is what a passenger cabin on a space ship would look like.

I was to receive intravenous medication following a protocol of precisely increasing amounts over several hours, so I lay back, opened my book, and relaxed while surrounded by all this reassuring technology.

And then I saw it. There stuck to the top of my chart…right there next to my chair… hardly noticeable…seemingly insignificant in the midst of all this electronic wizardry…nicely framed by electric wires and IV tubing…was a small piece of yellow paper.


On it was written the settings for the proscribed stepwise increase of my medication.The physician’s orders were computerized. The pharmacy’s filling of that order was computerized. My registration and ID bracelet were computerized. My clinical record for the day was computerized. The correct step-wise increase of medication for my weight had been calculated and displayed by the computer at the nurse’s desk. …But, that computer couldn’t “talk to” the infusion pump computer, so the actual entry of correct information into that infusion pump by a nurse for each of 10 stepwise increases depended on that Yellow Stickie.

When my chart got covered by a discarded newspaper the Yellow Stickie was temporarily “lost” which caused a brief flurry of nurse concern. It was moved to the blue plastic of the infusion pump which repelled the Yellow Stickie in a few minutes. It was next moved to the center of the IV pole itself, and there it stood, prominently and proudly revealing its data for the nurse as she entered the numbers every half-hour or so on the touch screen below. …That is, until the Stickie became unstuck while I was in the bathroom and fluttered silently to the floor, just missing the toilet bowl. An extra piece of scotch tape solved the problem of a Stickie not being sticky enough.

The medication was delivered as on the protocol, so all is well that ends well. My next post in two weeks will review some of the new data on clinical errors associated with computer use. I may title it, “THERE AIN’T NO FREE LUNCH.”

Herbert Mathewson, MD, blogs at HUB’s LIST, a compilation of medical fun facts gleaned from a variety of medical journals, newspapers, other public and professional sources, and an occasional private communication.

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4 replies »

  1. In our computerized, techno-savvy age, we still rely on something as basic as the little yellow sticky note in the patient care arena. — Daphne Berei

    People tend to rely on what they can see and whom they know. Funny though, if a yellow sticky (that you did not place) appeared on an infusion pump, would you automatically trust the information it contained? Or would you need to verify that yellow sticky by reading the chart for the patient? What if someone transposed a number on the note? That would constitute a mistake, and possibly a mistake with dire consequences. Machines, as do all human constructs, “make mistakes” or as is more popularly called in software engineering “generate errors”. Proper debugging of the software prior to its release can only minimize failure conditions. Even so, all software will only function as well as its programming model can address “real world” scenarios. Put more simply, the control software that operates the infusion pump only knows what to do because it was programmed to do those things.

  2. In our computerized, techno-savvy age, we still rely on something as basic as the little yellow sticky note in the patient care arena. This is probably because the people delivering the direct patient care aren’t fully confident that the “machines” don’t make mistakes, or could it be that the nursing staff utilize this as a way to double-check the machines? Either way, this is an added step to what the computers were designed to do: eliminate or reduce errors, and streamline care! Being a nurse in the acute care arena, I have packs of the neon post-it notes handy each day!

  3. An amusing piece of anecdote to be for sure! At the center of all of the “hub-bub” surrounding the evolution/revolution of provider workflows, collectively known as “reform”, we still see the people involved in the day to day performance of the workflows. Sure, your charts are now computerized. The pharmacy, possibly a robot in some cases, is computerized. Even the nurses stations are computerized. Gone, for the most part, are the large filing cabinets filled with colorful folders and reams of patient data. But not gone are the principle players in health care, the patient and the provider. As long as the provider is striving to provide to the patient, there will be a way. In this case, a yellow sticky note. Funny how it seems the simplest solutions are always the ones that work the best. Maybe not always the most efficient, in this case the nurse’s station couldn’t communicate with the infusion pump. But definitely the easiest to implement and maintain. Even with the issue of degrading stickiness, some engineering spirit identified a “work around” through the use of tape. Perhaps that’s what should be driving real reform. What makes a provider able to provide in the easiest most maintainable manner? Sure, we have washers that can communicate with dryers to provide the dryer with enough data to pre-select the appropriate cycle settings. Is that what we need in health care? Or do we just need the ability to provide to the patient in the most economical and implementable manner, even if not the most efficient.

  4. This post is both amusing and scary.Oh, how well I remember those yellow stickies! Just hope they get stuck on the right chart….