I hope the mere reading of the title made you queasy—it makes me shudder every time. On October 6th, CNN posted a story about a woman from Phoenix, Arizona, who accidentally put drops of super glue into her eye instead of the eye medication. She called 911, and in the emergency room the doctors had to cut open her eye and peel the hardened layer of super glue from her eye ball. If this doesn’t make you sick, then…

One may ask: how stupid does one have to be to glue their eye shut? But, as with many other product-use errors, the woman made a very common mistake. The hospital wasn’t surprised—apparently these accidents happen all the time. Because of poor vision, she couldn’t distinguish between the bottles of her eye medicine and the package of super glue.

Take a look at this:

If you are relying purely on feel, the woman’s error no longer feels so outlandish. Here’s what she probably could see with her poor vision:

And here is what we, the well-sighted, could see:

So upon a close examination, the woman’s error is a natural mistake. (Yeah, I know, I know: Why would she keep the bottle of super glue next to eye medicine? But it would be easy enough to come up with circumstances where this makes sense: she had to repair a pair of glasses, for example.)

So who’s at fault? The super glue manufacturers never considered their product in relation to eye medication. But once they were made aware that this product error happens all the time, they had to take action. This is a packaging design error that causes serious harm (think back to the cutting and peeling). As product designers, we have to strive to minimize product use errors. And this super-glue-in-the-eye error could be easily avoided by design.

Just one final note. In 2007, the Pennsylvania Patient Safety Authority came out with a report on the frequency of drug mix-ups in the hospitals due to similar packaging and sound-alike drug names. This report lists error after error by medical personnel that cause patients harm. And, of course, Pennsylvania is not unique. In 2009, Dennis Quaid and his wife received $500,000 compensation from the hospital that accidentally overdosed his babies with blood thinner heparin due to packaging error. I’m sure the Quaids would rather their twins had never been exposed to life-threatening danger.