At Tervanil in 2005, I approved a symmetric outer-carton prototype because it appeared orderly and consistent across the proposed range. A study used 120 dummy cartons with thirty-six packroom staff. Fourteen participants were confused about orientation at the initial opening. The materials contained no medicine, and the observation concerned a packaging task rather than a dose, treatment or patient outcome.
Rohan Kelvarne challenged my preference for the visual symmetry. The design sponsor wanted to explain the opening more clearly during demonstration and preserve the existing appearance. I accepted that an explanation supplied by the presenter could conceal a cue the product itself needed. The correction would change the opening signal rather than treat the confused participants as people who simply required a better introduction.
₹68 lakh supported development of an asymmetric opening cue and further review. Quality and regulatory colleagues retained responsibility for any relevant assessment; the product change did not alter a medicine label or imply permission to change regulated content. The follow-up involved thirty staff, five of whom still showed confusion. That was a different participant group and an unresolved prototype result, not evidence that every original problem had disappeared.
We retained another review instead of describing the packaging as finished. The team had given up an appearance it preferred and incurred rework because the opening task had not received enough attention in the first decision. I owned the approval that created the problem. I did not claim that the revised cue had reduced patient harm, prevented a clinical error or established universal usability.
The episode changed how I ask to see a physical prototype. I want to observe the task without relying on a presenter to supply the product’s missing meaning, and I want the limits of the observation preserved. A cleaner-looking object is not necessarily a clearer one to use. The correction was worthwhile because it addressed the defined task, while the remaining confusion required further work rather than a more confident statement about the result.