Forgot your password?
typodupeerror
Medicine Hardware Hacking News

CT Scan "Reset Error" Gives 206 Patients Radiation Overdose 383

Posted by Soulskill
from the paging-dr-simpson dept.
jeffb (2.718) writes "As the LA Times reports, 206 patients receiving CT scans at Cedar Sinai hospital received up to eight times the X-ray exposure doctors intended. (The FDA alert gives details about the doses involved.) A misunderstanding over an 'embedded default setting' appears to have led to the error, which occurred when the hospital 'began using a new protocol for a specialized type of scan used to diagnose strokes. Doctors believed it would provide them more useful data to analyze disruptions in the flow of blood to brain tissue.' Human-computer interaction classes from the late 1980s onward have pounded home the lesson of the Therac-25, the usability issues of which led to multiple deaths. Will we ever learn enough to make these errors truly uncommittable?"
This discussion has been archived. No new comments can be posted.

CT Scan "Reset Error" Gives 206 Patients Radiation Overdose

Comments Filter:
  • by s73v3r (963317) <s73v3r@gmail.cPASCALom minus language> on Wednesday October 14, 2009 @12:44PM (#29746441)
    As long as people are involved in some way, no.
    • by courteaudotbiz (1191083) on Wednesday October 14, 2009 @12:52PM (#29746559) Homepage
      Mmmmm, anyway, people are always involved if you have a machine. The machine didn't build itself!
    • by Alaren (682568) on Wednesday October 14, 2009 @01:20PM (#29746893)

      This is probably modded insightful because we're all familiar with "human error," but it misses the point of the article (and is sort of misanthropic, too).

      This particular error is the kind that occurs when you simplify complex procedures in the interest of widespread use. It is the fault of specialization, which we typically embrace because it allows us to leverage human labor into increasingly complex areas of inquiry. It's more than just "human oversight" or "machine failure," it's the kind of problem that typically arises when people are trained to use machines without being trained to fully understand those machines.

      A certain segment of society--that's mostly us geeks--strives against this tendency; we become technicians in various fields. But most people, including medical people, get trained by vendors to use a particular piece of software or hardware without reference to its underlying principles or inner workings. This is normal and usually beneficial for various reasons an economist could doubtless relate.

      The sad reality is that, so long as it doesn't kill too many people, any innovation that leads to greater economic efficiency will be accepted and embraced. The obvious example is automobiles, which (even adjusting for factors like alcohol) kill a startlingly large number of people. Those deaths are mourned, but ultimately absorbed by the human race as the cost of doing business. This makes some people resent automation, resent technology, et cetera... but most of us find other ways to cope.

      • by antifoidulus (807088) on Wednesday October 14, 2009 @01:30PM (#29747049) Homepage Journal
        The advantages of simplified training are not just beneficial on an economic scale. While its unfortunate that this error killed people, think of how many more people would die if complex training was required to use these types of machines. Ultimately, it would lead to fewer operators and thus less access to the machine, which ostensibly helps save lives.
        • Re: (Score:3, Informative)

          by westlake (615356)

          While its unfortunate that this error killed people

          There is no mention of any deaths.

          Even under normal circumstances, the procedure requires more radiation than most other types of CT scans. Radiation exposure increases the likelihood of cancer, though the risk is lower in older patients because they are likely to die of other causes first.

          The median age of these patients is 70 years - and they are surely far more at risk of a second - more dibilitating - stroke than a cancer that might not manifest its

      • by digitig (1056110) on Wednesday October 14, 2009 @02:02PM (#29747467)

        This particular error is the kind that occurs when you simplify complex procedures in the interest of widespread use. It is the fault of specialization, which we typically embrace because it allows us to leverage human labor into increasingly complex areas of inquiry. It's more than just "human oversight" or "machine failure," it's the kind of problem that typically arises when people are trained to use machines without being trained to fully understand those machines.

        A certain segment of society--that's mostly us geeks--strives against this tendency; we become technicians in various fields. But most people, including medical people, get trained by vendors to use a particular piece of software or hardware without reference to its underlying principles or inner workings. This is normal and usually beneficial for various reasons an economist could doubtless relate.

        But one of the things that we geeks should be doing is looking at equipment like this in its overall system context, which includes the operator and which includes the training the operator has received. That's mandatory in the Aviation industry pretty much worldwide (my field); I don't know what the situation is for medical equipment in the USA. No, we will never make such mistakes "uncommittable" -- perfect safety is a myth. But we should be considering possible failure modes, and the likelihood and consequences of those failure modes, to ensure that the risk is tolerable.

      • Re: (Score:3, Interesting)

        by jimicus (737525)

        I don't know about the US, but in the UK the qualification you take to give CT scans these days is usually a degree - you'd be a diagnostic radiographer. How much more training do you want?

        The problem isn't the qualification, it's the change in protocol. Someone thought it would be a good idea to override the machine's inbuilt safety cutout by resetting it part-way through the scan, proving that being highly qualified is no barrier to making dangerous decisions.

    • As long as people are involved in some way, no.

      Indeed. The problem here is that whenever you have to communicate something, there's no way to be 100% sure that 100% of your users will see what you intended, in the way that you intended it. You can explain everything perfectly clearly and concisely - but because humans don't read minds, all words and visual cues are subject to interpretation by indviduals.

  • by PhasmatisApparatus (1086395) on Wednesday October 14, 2009 @12:44PM (#29746447)
    Requiring that doctors RTFM is the first step.
    • by betterunixthanunix (980855) on Wednesday October 14, 2009 @12:49PM (#29746493)
      The machine's software should not be capable of triggering the release of that much radiation; any change in the radiation levels should require some kind of hardware interaction. Even an idiot who did not RTFM should not be able to cause harm with the machine.
      • by vertinox (846076) on Wednesday October 14, 2009 @12:58PM (#29746627)

        The machine's software should not be capable of triggering the release of that much radiation; any change in the radiation levels should require some kind of hardware interaction. Even an idiot who did not RTFM should not be able to cause harm with the machine.

        I'm not sure what you mean by this? Most hardware is software these days.

        Or are you talking about having a red button with a safety lock on it that has to be pushed in order to work?

        Either way, people still bypass hardware solutions.

        • by Serenissima (1210562) on Wednesday October 14, 2009 @01:07PM (#29746761)
          I think he means it should be hardwired into the unit to NEVER EVER exceed a certain level of X-Ray radiation. That should be the default. If there's some medical reason why the dosage needs to increase, you should have to turn it UP to that dosage and then the machine should reset itself to the default. There should NEVER be a problem of the machine defaulting to an extremely high level of radiation requiring personnel to turn it down. It should always start out low in case some dumbass technician runs the machine without making any changes.
          • by Sockatume (732728) on Wednesday October 14, 2009 @01:30PM (#29747043)

            Don't even hard-wire it. Engineer it so that operating in the high-dose regime requires physical intervention, a "Kill Handle" with a lock and key. The machine should be physically incapable of generating an above-standard dose when the "Kill Handle" is not being held. Limit the power, or something. (The aformentioned Therac incident happened, in part, because such a hardware interlock did not exist.)

            • Re: (Score:3, Insightful)

              by Darinbob (1142669)
              And as I posted earlier, customers have been caught with weights to hold down buttons.

              In this particular case though, that particular dosage may have been appropriate to some uses, but not others. A "maximum allowed dose" can be in effect and still make a patient sick!

              For some machines these doses are controlled mechanically; moving heavy lead and steel plates around, irises, etc. Hardwiring a maximum dosage in this case involves the interaction between many components.
            • Re: (Score:3, Insightful)

              by nobodyman (90587)

              he aformentioned Therac incident happened, in part, because such a hardware interlock did not exist.

              Ironically, earlier models of the Therac device *did* have hardware interlocks. These earlier models shared the same software defects as the Therac-25, but hardware interlocks prevented the overdose scenario.

              I haven't RTFA, and I don't even pretend to assume that I could do things better (or even fully grasp the problem). That said, the struggle for efficiency and programmers' tendency to seek out a softw

        • "Most hardware is software these days."

          Therein lies the problem. There should be a hardware mechanism that limits the maximum power the machine can operate at, despite what the software requests. If there is a reason to increase that limit, it should have to be done in hardware, using a mechanism that automatically resets after a single run. The process of overriding the hardware limit should be conspicuous: nobody should be able to do it without intending to do so. Preferably, it should be obvious
      • /agree. Was just going over this w/ someone in the field. It's amazing that it happened in the first place, more amazing that almost 200 patients went by before this was caught. If that happened at a larger hospital it SHOULD have been in the thousands.

      • by snowraver1 (1052510) on Wednesday October 14, 2009 @12:59PM (#29746639)
        Hardware interaction... Like maybe "[...]resetting the machine to override the pre-programmed instructions that came with the scanner when it was installed."?

        I'm willing to bet that the person that modified the machine has read, at least, the relevant parts of the manual.
      • by Greyfox (87712) on Wednesday October 14, 2009 @01:36PM (#29747111) Homepage Journal
        My machine would irradiate the operators by default and would require that a obscure button sequence be pushed in order to irradiate the patient instead. That way the idiot who didn't RTFM would end up dying of radiation poisoning, not the patient. Eventually the survivors who DID RTFM would breed and pass on their proclivity to RTFM. Really it's for the good of the entire human race, if you think about it...
      • by BigDukeSix (832501) on Wednesday October 14, 2009 @02:12PM (#29747613)
        It's not quite that simple. The CT scanner is set up with a distinct scanning protocol for whatever part of the body you're imaging. If you're trying to get a detailed image of the bones of the pelvis you have to use more power than if you're imaging the lungs. The scan is further individualized by patient size. Given that infants and very large people are imaged on the same scanner, the software has to vary radiation dose over a reasonably wide range, and it's a different setting for every scan.
      • by Geoffrey.landis (926948) on Wednesday October 14, 2009 @02:17PM (#29747677) Homepage

        The machine's software should not be capable of triggering the release of that much radiation

        That sentence, essentially, just said "The machine did something bad. It should have been designed so it isn't allowed to do that."

        That's what qualifies as "insightful" these days????

      • Re: (Score:3, Insightful)

        by LWATCDR (28044)

        "Even an idiot who did not RTFM should not be able to cause harm with the machine."
        But was this above that limit?
        Different scans REQUIRE different amounts of radiation.
        Nothing can be fool proof. I would bet that there is a limiter but this level could be below that limiter.

    • by smitty777 (1612557) on Wednesday October 14, 2009 @12:55PM (#29746587) Journal

      Couldn't disagree more. Unfortunately, enforcing training and reading manuals would probably have little effect. In my 10+ years doing usability for missile systems, you have to build in the mechanisms to keep the users from doing bad things. Even if you force the user to read the *entire manual* before each use, people still have bad days, hangovers, fights with significant others. It has to be designed in.

      • Re: (Score:3, Interesting)

        by NonSequor (230139)

        Couldn't disagree more. Unfortunately, enforcing training and reading manuals would probably have little effect. In my 10+ years doing usability for missile systems, you have to build in the mechanisms to keep the users from doing bad things. Even if you force the user to read the *entire manual* before each use, people still have bad days, hangovers, fights with significant others. It has to be designed in.

        The story behind Murphy's Law [wikipedia.org] is pretty interesting and it ties in with this design philosophy.

        Basically the story is that a technician incorrectly installed force sensors and in response, Murphy got pissed off and said "If that guy has any way of making a mistake, he will."

        However, other people adapted that statement into "If anything can go wrong, it will," expressing the idea that if a system does not mechanically exclude the possibility of human error, human error can be expected to occur. This makes ac

    • "You have to be pretty confident to think you know more than the guys who designed the equipment."

      I think it speaks volumes. I don't think they would RTFM even if you threatened them it would be a conflict of their personality.

    • Being in the medical field these days (though not in the nuclear medicine area) I can say that doctors are even less likely than CS geeks to RTFM. It is always the engineer's responsibility to take all reasonable steps to ensure that a system can not cause harm to patients, doctors or technicians, even if used improperly.

      The fact that nuclear medicine equipment continues to ship without an absolutely paranoid level of hardware safety interlocks 20+ years after the Therac-25 incidents is appalling.
  • Default setting... (Score:5, Insightful)

    by courteaudotbiz (1191083) on Wednesday October 14, 2009 @12:47PM (#29746475) Homepage
    The default setting for an equipment that can be lethal should be "Emit zero radiation". Then for each exposure, set the level of radiation you intend to use. This way, you ALWAYS KNOW the level of radiation the equipment will emit.

    Better investigate "Hey, we got no picture" than "Hey, we got pictures, but everyone dies after that..."

    Didn't RTFA.
    • by eln (21727) on Wednesday October 14, 2009 @12:52PM (#29746551) Homepage
      That's really not fair...you have no idea that people would die from that radiation. It's at least equally likely they would develop super powers, join up with others who have received similar doses of radiation, and form a crime fighting team of mutants.

      All I'm saying here is we shouldn't just dismiss this as a bad thing until we've fully explored the legislative and societal implications a team of crime-fighting mutants with superpowers would have.
      • They wouldn't really be mutants, maybe amazing, fantastic or incredible, but not mutants.
      • by eleuthero (812560)
        I want to see your remarks as funny--I do. And if I hadn't read the article already (*gasp* I may lose my account now), I probably would, but it would seem that the current problem in conjunction with historical issues with scanning devices make it a rather serious and dark matter for me. There should be hardware locks against overusing the machine. It should have a zero default setting and it should be impossible in the hardware to make the thing go beyond the normal tolerance for an adult with cancer (oth
    • by DomNF15 (1529309)
      Agreed - looks like the embedded software developer didn't follow tenet 1 of the soft dev. process, i.e. assume the user is an idiot. It should always default to some "safe" value.
    • Re: (Score:3, Insightful)

      by fluffy99 (870997)

      Didn't RTFA.

      Well that explains why your comment makes no sense. The system was showing a correct dosage, but was delivering something different since they had been dorking with the protocol definitions. In the Therac-25 case, the error was due to the operators using the program in an undocumented manner and the system incorrectly calculating the required exposures as a result. Also the operator doesn't arbitrarily set a level. He picks a specific protocol from a menu which already has the scanning pattern, timing,

  • HULK MAD! (Score:5, Funny)

    by BumbaCLot (472046) on Wednesday October 14, 2009 @12:47PM (#29746477)

    Even under normal circumstances, the procedure requires more radiation than most other types of CT scans, said David Brenner, director of radiological research at Columbia University Medical Center in New York.

    Anyone else read this as David Banner?

    • Re: (Score:3, Insightful)

      by frito_x (1138353)

      Hate this "immediately moderate when you select an option" feature. meant to mod funny... slip of the mouse goes to overrated... there should be a go/ok button next to the list imho.

      wasted 3 mod points... oh well...
           

  • The error went unnoticed for the next 18 months, until this August, when a stroke patient informed the hospital that he had begun losing his hair after a scan.

    There's only a factor of 8 difference between a typical scan dose and one large enough to cause hair loss and skin damage? IIRC observable damage doesn't occur until the hundreds of mSv range. I'm pretty astonished that CT scans need such huge doses.

    • by argent (18001)

      There's only a factor of 8 difference between a typical scan dose and one large enough to cause hair loss and skin damage?

      Yeh, that's what I was thinking. I thought that X ray machines were designed to stay well away from dangerous levels these days. I'll keep that in mind next time my doctor suggests a CT scan.

    • Well think about it for a sec. They're getting high resolution images of tissue and fluid, not just bone.

      You would expect that to require large, large doses to achieve.
    • Re: (Score:2, Informative)

      by celticryan (887773)
      Re:

      100s of mSv range

      There are portions of the world that have a very high natural background in the 200 mSv range so you are not quite right with your estimates. In addition, you have to distinguish between whole body dose and localized dose. It is not uncommon to see tumor doses in the 40-50 Sv range.

      The machines were set for .5 Gy (for xrays 1 Gy = 1 Sv) and got 3-4 Gy. A whole body dose of just above 4 Sv is a 50% death in 3-6 weeks (with no medical intervention). (remember that the CT was only to the brain). The

      • The high natural background areas deliver the 200 mSv over a period of a year though, not a matter of minutes.

        There may be good medical reasons for using such enormous doses, but it still took me by surprise. The average dose of a nuclear worker is only a few mSv/year. Still, I guess a 1 in 40 chance of the radiation causing a fatal cancer isn't so bad if it stops you dying from a stroke in the meantime.

    • by Amouth (879122)

      but CT scan's aren't "typical" - you get xray'ed couple times a year so they are very low poweed, but a CT scan?? i think my last was? i might have had one 25 years ago when they cut my head open, for that they pump up the power to get it right.

  • by uncledrax (112438) on Wednesday October 14, 2009 @12:50PM (#29746523) Homepage

    Maybe next time they will test the damn thing before subjecting patients to it? It's a built in part of my job that I test/confirm a change after I make a change.. because often there's a likely hood of something unexpected or improperly explained that can cause an issue.

    How hard would it have been to stick a dosimeter in the machine after the change and run it though a test?
    (I realize that just a basic dosimeter might not be a sufficient measure.. but it would have been good to get a before/after.. and something like a 8-fold increase would have been easily detectable!)

    • Maybe next time they will test the damn thing before subjecting patients to it? It's a built in part of my job that I test/confirm a change after I make a change.. because often there's a likely hood of something unexpected or improperly explained that can cause an issue.

      So, what you're saying is, "Always mount a scratch human."

    • by RDW (41497) on Wednesday October 14, 2009 @01:19PM (#29746887)

      'How hard would it have been to stick a dosimeter in the machine after the change and run it though a test'

      Supposedly the actual dose would have been displayed on the machine's screen (I wonder how prominently?):

      http://www.latimes.com/news/local/la-me-cedars-sinai14-2009oct14,0,5065886.story [latimes.com]

      '"It's in your face on the screen," said Dr. Donald Rucker, chief medical officer for Siemens, a manufacturer of CT scanners.'

      'CT technicians are trained to monitor dose levels, and some hospitals conduct checks before every scan..."There are other places where the techs might be operating more as button-pushers," said Dr. Geoffrey Rubin, a professor of radiology at Stanford University. "The user becomes a little blind to these numbers."'

    • by Geof (153857)

      The article is not very detailed, but my reading of it is that the default dose was not unsafe. If I am correct (hard to tell), what happened was that a doctor doing a specialized procedure programmed a custom dose. Then the machine defaulted to this new value for subsequent procedures, but the staff assumed it was using it's previous (safe) default.

      There was a misunderstanding about an embedded default setting applied by the machine . . . Once the scanner was programmed with the new instructions, the hig

  • by HNS-I (1119771)
    While the hospital shouldn't have gone and reprogram the instructions, this should have been prevented at hardware level. The machine should register a patient checking in and the amount of radiation emitted.
  • In short (Score:2, Insightful)

    by Cornwallis (1188489)

    Will we ever learn enough to make these errors truly uncommittable?"

    No.

  • Doctors are woefully unaware or unwilling to admit that CT scans do involve some risk because they very well can give appreciable radiation dose, often far more than that of standard radiography. They are largely viewed as harmless given the excellent volume of anatomical information they provide, and while they do offer immense benefit, it is vital that the radiation hazard be comprehended. I hope that doctors and technologists will take away from this the lesson that they do need to be aware of radiation
    • I think doctors, machine designers, and everyone else involved are aware of the increased radiation associated with CT scans. But if you've got someone presenting with stroke symptoms, you're balancing "additional 1 in 10,000 lifetime risk of cancer" against "irreversible brain damage increasing in severity with each passing minute". If I'm ever in that situation, I'd tell them "cook me as hard and fast as you like, and I'll deal with the side effects at my leisure."

  • When I witness this constant chase of removing risk from the world it makes me wonder if it's delusion or just plain stupidity. No matter how hard you try there will always be risk involved in almost every action. Accept it and treat it rationally. I'm not saying to ignore it. Just to accept it as life. Life is brutal.
    • Re: (Score:3, Insightful)

      by Entropius (188861)

      Life is brutal, but that doesn't mean we should give up on trying to make it less so. Asking whether CT scanners can be redesigned to make this not happen, and whether it's worthwhile to do so, is very valid.

    • It isn't removing the risk that's an issue - it's calculating the risk benefit ratio and, in this case, understanding what you're doing. While we don't have enough information to really know what happened (not that this sort of this ever stops us here), it seems like the staff the overrode the built in protocols didn't think it through well enough or perhaps didn't RTFM.

      It is heartening to note that at least the new GE Brightstars's print out the radiation exposure given with each study as part of the ro
    • by eleuthero (812560)
      How far does "acceptance" go? Being horrified at problems and seeking to address them seems like a proper response--humans are not just machines--emotional responses indicate acceptance on many levels, not just the intellectual.

      And while this may or may not apply to your particular comment (depending on your meaning), if we didn't work to remove unnecessary risk from the world, there would be no fire, no stick clubs, and we would all be living in trees trying to hide from tigers and lions--when they didn'
  • by CheddarHead (811916) on Wednesday October 14, 2009 @12:58PM (#29746617)

    Along with the usability issues with the design of the Therac-25 it's obvious that the attitude of the medical staff contributed greatly to the problem. Patients complained of being burned, but their complaints were essentially ignored. Meanwhile, they were sent back for multiple treatments. Overwhelming evidence of radiation burns was ignored or given only cursory investigation because medical personal or manufacturer reps claimed that it was impossible for the Therac-25 to be responsible for the burns.

    • Re: (Score:3, Informative)

      by Svartalf (2997)

      If you read the history...about half of the deaths were due to one-shot incidents where the patent received a lethal dose out of the machine on the first treatment. To be sure, some of the incidents should have been dealt with differently as you indicate- but what about the Tyler, TX incidents, for example?

      Yes... Medical Staff are a big part. But so was the manufacturer of the device- had you read all the evasiveness on AECL's part when the problems started coming in. In the case of the first incident,

  • Before you all get worked up realize that 8 times the intended dose does not mean it was over the exposure limit or dangerous levels. That too just 200 people. Come on get some perspectives ok? It was not long ago we were permitting shoe salesmen to Xray the foot to check the fit of shoes on people. And it was not even pulsed. Continuous, high level radiation.

    For comparison remember more people are killed by vending machines and by falling off the roof putting up the christmas lights.

  • Meh... (Score:2, Funny)

    by Machupo (59568)

    What's a few hundred rem among friends?

  • by TemporalBeing (803363) <bm_witnessNO@SPAMyahoo.com> on Wednesday October 14, 2009 @12:59PM (#29746643) Homepage Journal

    Will we ever learn enough to make these errors truly uncommittable?"

    There is and never will be such a thing as a machine without the possibility for error. And you'll never get around the old adage/rule - If it can happen, it will. How often it occurs it the key; and while we should always aim to make an error-less machine, it is an impossibility and we can only achieve it by make the occurrence of such errors as few and far between as possible.

    After all, an error-prone human must be involved to make the machine; even if that machine made another machine a human was still involved at some point to make the original. Thus there will always be the possibility for errors. Even if, as demonstrated by the Matrix, iRobot, and many others, the machines make that error on purpose to save humanity - it is still an error.

  • Film badges? (Score:3, Interesting)

    by johnny cashed (590023) on Wednesday October 14, 2009 @01:02PM (#29746673) Homepage
    Would a film badge provide a "check" to determine if the dosage is correct? One x-ray overdose is bad enough, over 200 is really uncool.
  • Perhaps having the equivalent of IRB review over any changes to devices of this sort would help prevent such problems. It makes sense for devices to be reconfigurable, and it makes sense for devices to try to warn people away from doing stupid things. In this case, they overrode the safeguards, and their judgement happened to be worse than that embodied in said safeguard. That is not always the case - the problem is when people make changes with potantially lethal consequence and there are not enough eyes o

  • Feedback? (Score:5, Interesting)

    by TopSpin (753) * on Wednesday October 14, 2009 @01:10PM (#29746789) Journal

    Will we ever learn enough to make these errors truly uncommittable?"

    No. As long as correctness can't be proven and operators are permitted to create unanalyzed conditions by altering protocols there will always be risk. There are probably other mis-configured CT scanners out there in use right now that have been overdosing patients for years.

    CT scans use X-rays; an easily detected frequency of light. Why not require that scanners incorporate an independent detector that measures the amount X-ray energy? If that is possible then create an interlock that can shut down the emitter when the net energy gets out of bounds and require that any such incident be NRC reportable. If the detector excluded from alteration by the operators then software bugs, misunderstandings, etc. can be detected even years after the last engineer had contact with the system, either before harm is done or at least before hundreds of patients are literally burned.

    • by _LORAX_ (4790)

      A hardware X-Ray "circuit breaker" that would physically trip the power to the CT scanner if levels are exceeded? Not a bad idea. I would also require a monthly/quarterly test of the equipment by intentionally running it slightly over it's rated threshold.

  • Is the lack of patient participation in their own health initiatives.

    Approximately 90 people over 18 months suffered hair loss and/or burns on their head, and not one of them reported it.

    Patients need to wake up and realize doctors and the medical establishment try to do their best, but they are only human and a vast majority of what they do is simply educated guessing.

    The patient is ultimately responsible for his/her own health care, so drill the doctors and do not let them get away with brushing
  • For patients undergoing scans or treatments involving radiation, why not verify exposure with a 25 cent dosimeter? You'd catch problems right away.
  • There are very strict regulations on what radiation is acceptable. Why did the not add a failsafe or critical warning, something like a big red blinking message "What you are gonna do is probably stupid" or so?! Just to give the therapist a hint that something is wrong. I mean, implementing this kind of failsafe should not pose that much of a problem, would it?

  • Sound familiar to anybody? Hope you enjoy that next doctor visit, plane ride, etc.

    Hey, I hear they want to make a smart grid! Any takers on reliability? Anybody?

  • Oh great (Score:3, Funny)

    by Tony Hoyle (11698) <tmh@nodomain.org> on Wednesday October 14, 2009 @01:34PM (#29747091) Homepage

    Now there are 206 hulks running around.

    Just don't make them angry.

  • Does anyone here who posted on the subject, know what the fuck they are on about. And can we really believe the published reports ..
  • "There was a misunderstanding about an embedded default setting applied by the machine . . . ," officials at the renowned Los Angeles hospital said in a written statement that provided no other details about how the error occurred. "As a result, the use of this protocol resulted in a higher than expected amount of radiation."

    The dose of radiation was eight times what it should have been.

    Once the scanner was programmed with the new instructions, the higher dose was essentially locked in. Each patient w

  • by ArcadeNut (85398) on Wednesday October 14, 2009 @02:37PM (#29747971) Homepage

    That pops up for the operator to respond to....

    Are you sure you want to kill this patient?

    Yes No Retry

  • by goodmanj (234846) on Wednesday October 14, 2009 @02:59PM (#29748283)

    Typical normal CT scan dose: 1-2 rem
    Faulty CT scan overdose: 8-16 rem
    1950s shoe-salesman's fluoroscope: 10 rem
    Typical normal Therac-25 dose: 200 rem
    Malfunctioning Therac-25 dose: 15-20,000 rem

    Come on, seriously people. Yes, this is a mistake that needs to be fixed, but millions of kids in the '50s got their feet nuked with this much radiation and lived to become healthy normal adults with normal feet.

    The Therac-25 cooked straight through people, leaving a hole of rotting meat behind. This is not even remotely in the same league.

    http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/R/Radiation.html [rcn.com]
    http://chestjournal.chestpubs.org/content/107/1/113.full.pdf [chestpubs.org]
    http://www.ccnr.org/fatal_dose.html [ccnr.org]
    http://www.orau.org/ptp/collection/shoefittingfluor/shoe.htm [orau.org]

Simplicity does not precede complexity, but follows it.

Working...