I read today about a recall of birth control pills. The detail that caught my attention was this:
Blister packs of the birth control pills were rotated 180 degrees, which reverses the weekly tablet distribution. This packaging error could cause women to take pills in the incorrect order and could lead to unintended pregnancy.
I suspect this means someone at the factory put the empty blister packs into the packaging machine upside down.
Buddha wept, this is Industrial Design 101. If you have an integration process where orientation is important, you avoid this kind of disaster by enforcing orientation through asymmetry. You can't plug a USB cable in upside down because the plug is asymmetrical along the critical axis. You shouldn't be able to load unlabeled blister packs into a machine upside down, nor should it be possible to fill and label those blister packs. All it would take is a notch in one corner to ensure orientation.
I'm sure press people would assure me "it's more complicated than that." No, it's not. I could be wrong about the mechanical particulars, but issues like this represent a systems design mistake of a real-world artifact: somewhere along the way a physical template, die, guide, measure, or clamp that could have been designed to prevent this from happening was not.