It's often the little things (or in this case, the big things) that matter to patients.
In this case, a 12-year old presenting with an ongoing ear infection is prescribed amoxicillin.
The prescribed treatment was perfect; a 10 regimen of antibiotics to thwart the bacteria residing in her ear.
However, the patient can't swallow (nor could I as an adult) a pill this size.
To a young child, a pill at this size causes fear, panic and frustration. Even worse, there is a grave chance that the much-needed medicine won't be consumed, thereby negating the positive effects that brought it about in the first place.
It is times like this that I am sure a simple process designed to remind the clinician, nurse or pharmacist of whom they are treating would have alleviated the entire situation.
What if there had been a simple system prompt before the script was filled with a note on specific patient needs? Something as clear as "Can patient tolerate pills?" easily would have remedied this problem.
This is why we need patients to be part of the system at the start of design; so 12-year olds aren't paired with pills meant for adults.
Together, we can make a difference.