911 Operator Error or Software Design Flaw?

There was a sad story last week in the Pittsburgh Post-Gazette about a 3-week old baby which had stopped breathing who received delayed emergency care because Allegheny County's Emergency Services paramedics were sent to the wrong address by a 911 dispatcher.

According to the Post-Gazette story, the 911 dispatcher mistyped the address of the location of the emergency call. As described by the Post-Gazette: 

"The county uses a computer-aided dispatch system supplied by Tiburon Inc. The dispatcher had typed the correct street address on Crucible Street for the call, [Allegheny County's Emergency Services] Chief Full said. When she went back to modify the address by including an apartment number, she mistakenly typed the '@' symbol rather than the '#' symbol, he said. The two keys are next to each other. Because of a glitch in the computer program, that small error resulted in the address being changed from 'Crucible Street' to 'Crane Avenue.' "

The change in address delayed the paramedics by some seven minutes. The baby died an hour later at the hospital, but the medical examiner said that the delay doesn't seem to have played any part in the child's death, which is still under investigation.

Chief Full did not blame the 911 software "glitch" as being a reasonable excuse for the delay, the Post-Gazette story reports, saying that the 911 operator had another opportunity to catch the error. The experienced emergency dispatch operator has been suspended from her job indefinitely without pay.

The Chief may be correct in saying that the operator should have caught the error, but it seems like a poor software design where a typo like the one described above  can completely change an address. It is bad enough that a "normal" typo can cause delays; 911 operators don't need to be fighting their dispatch software as well.

According to this related story in the Pittsburgh Tribune-Review, Tiburon is two months away from installing a new $10 million 911 dispatch system in the county. Chief Full, however, has asked that the company change the software in it and the current dispatch system to ensure that typos can't cause future problems.

I find it curious that this particular error has supposedly never been reported before, given that the Post-Gazette says that 1.3 million emergency calls were received in 2009 alone by Allegheny County's Emergency Services.

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