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Medicine Bug Science

Radiation Therapy Mistakes Cost Lives 215

Posted by kdawson
from the feel-the-burn dept.
jmtpi recommends a long NY Times investigative report about how powerful medical linear accelerators have contributed to at least two deaths in the New York area. Although the mistakes were largely due to human error, buggy software also played a role. "...the records described 621 mistakes from 2001 to 2008... most were minor... The Times found that on 133 occasions, devices used to shape or modulate radiation beams... were left out, wrongly positioned, or otherwise misused. On 284 occasions, radiation missed all or part of its intended target or treated the wrong body part entirely. ... Another patient with stomach cancer was treated for prostate cancer. Fifty patients received radiation intended for someone else, including one brain cancer patient who received radiation intended for breast cancer."
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Radiation Therapy Mistakes Cost Lives

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  • by timmarhy (659436) on Sunday January 24, 2010 @06:03PM (#30882740)
    year ago i worked in a pathology lab, and i can atest to the fact the medical field is populated with a lot of highly trained morons. many times the application of these treatments aren't done by someone with enough brain power to understand whats actually happened.
    • by Jophish (1489121) on Sunday January 24, 2010 @06:23PM (#30882912)
      Alternate title: Radiation Therapy Success Saves Lives
    • by Zerth (26112) on Sunday January 24, 2010 @06:35PM (#30883020)

      Indeed, most of these errors don't sound like Therac-25 type errors, more like PEBKAC errors.

      These can only be solved by double checking(more labor costs? not likely) or by patients who care enough about themselves to take a black marker and write "radiation goes here, dumbass".

      I've done similar things ever since I went in for an operation where they started the incision on the wrong side then decided they'd just go with it and tunnel across my abdomen instead of starting over in the right spot.

      • CHECKLISTS! (Score:4, Insightful)

        by bussdriver (620565) on Sunday January 24, 2010 @09:34PM (#30884576)

        CHECKLISTS! Pilots have an easy job and they need them. huge benefits resulted from giving them checklists.

        Doctors and medical workers must be forced to use checklists. period.

      • by Hadlock (143607) on Monday January 25, 2010 @01:40AM (#30886438) Homepage Journal

        Yep, my dad got radiation treatment, he got "gamma knife" treatment for brain cancer. You get a special plastic mesh helmet that is specifically molded to your head (for brain cancer paitents, it's molded to other parts for pancreas or breast cancer, etc paitents), and then there are marker dots on the mesh helmet that align with set lasers in the walls. so your body is properly aligned. Then the actual "gamma knife" is placed in the correct position so it creates a red + sign on the targeted area, which matches up with the plastic mesh helmet. Your name is also written on the helmet, and you fetch your own helmet from the same cubbie each time and put it on your own head. A tech makes sure it's secured and double checks that it's your helmet. Not only are you picking out your helmet, but they cross reference your name, and unless you have a very small head, only your helmet is going to properly fit you. The red + sign isn't going to lay "flat" and the laser dots won't line up. It's at least a triple redundancy mode of failure and it seemed to work pretty well. Added bonus: the table looks like that room in the bond movie where bond goes "you expect me to talk?" and the villan responds "no mr bond, i expect you to die! (maniacal laughter). It's kind of neat to do medicine in a room that looks like a bond villian's secret layer.

      • Re: (Score:3, Interesting)

        by Ihlosi (895663)
        I've done similar things ever since I went in for an operation where they started the incision on the wrong side then decided they'd just go with it and tunnel across my abdomen instead of starting over in the right spot.

        Well, they did the right (i.e. least risky) thing. Every hole cut into the bodys line of defense against the hostile exterior is a possible site for an infection, hence you want to keep the number and size of the holes as low as possible.

    • Yeah, I know. (Score:5, Interesting)

      by gbutler69 (910166) on Sunday January 24, 2010 @07:21PM (#30883408) Homepage
      These "Highly Trained Morons" are working on killing my wife. She went in for a Hysterectomy and ended up with her ureter sutured or cauterized shut resulting in her kidney backing up and shutting down. Now she has a tube out her back to keep her kidney alive and in a few weeks they'll go in an cut her ureter above the blockage and reattach it to her bladder. All for the low, low, price of $$$$$$$$$$$$. Meanwhile, the nursing staff and E/R staff have done everything in their power to see how much additional damage they can do. No one has any common sense or care that I can see. I'm fit to be tied!
      • I wish you both the best.

      • Re:Yeah, I know. (Score:5, Insightful)

        by Rob the Bold (788862) on Sunday January 24, 2010 @10:00PM (#30884850)

        These "Highly Trained Morons" are working on killing my wife. She went in for a Hysterectomy and ended up with her ureter sutured or cauterized shut resulting in her kidney backing up and shutting down. Now she has a tube out her back to keep her kidney alive and in a few weeks they'll go in an cut her ureter above the blockage and reattach it to her bladder. All for the low, low, price of $$$$$$$$$$$$. Meanwhile, the nursing staff and E/R staff have done everything in their power to see how much additional damage they can do. No one has any common sense or care that I can see. I'm fit to be tied!

        If you survive a hospital stay for anything serious, it's either luck or because you had reasonably intelligent friends and family looking out for you the whole time. Heaven help anyone without such a network of support. It helps if they're taking notes -- keeping their own charts, as it were. Twist all the arms you can, call in all your chips, and good luck.

      • ...to thank all those who expressed concern. Wasn't intended as a sympathy shopping expedition, but, thank you anyway.
    • Re: (Score:3, Interesting)

      by Hurricane78 (562437)

      Well, a doctor is only a apothecary with a tiny further training. Who after being finished, assumes that he knows everything and will continue to do so forever. If he does not know it, it does not exist. If he knows no cure, there is no cure.
      Also they are trained to “fix” the symptoms. (Which is practice means, to hide them under painkillers, so you can continue to ignore what you’re doing wrong.) Finding the causes is only happening in colorful Hollywood productions. In reality, it’

  • Breaking news (Score:5, Insightful)

    by rockNme2349 (1414329) on Sunday January 24, 2010 @06:07PM (#30882778)

    People make mistakes with technology which results in unintended consequences. Giving someone treatment for the wrong disease may have adverse side effects.

    Basically this only proves that people are stupid in general. I don't see anything wrong with this technology.

    • People make mistakes with technology which results in unintended consequences. Giving someone treatment for the wrong disease may have adverse side effects.

      Basically this only proves that people are stupid in general. I don't see anything wrong with this technology.

      So you don't see a problem with a machine that may be deadly if used improperly, but is too complicated for the intended users to use properly?

      Can you give me an idea of where you live? Because I'd sure love to move to wherever it is that all users are mistake-free geniuses.

      • by Nyeerrmm (940927)

        There's not nothing wrong with it, but if more people are saved by the technologies proper use than are injured by its improper use its probably worthwhile.

        Accidents happen, this is no different. The engineers of the equipment have a duty to make it as easy to use as possible, and the operators have a duty to understand it as best as possible -- this doesn't mean that accidents won't happen every once in a while, since as you point out we aren't all mistake-free geniuses.

        I see a few hundred mistakes out of

    • by SEWilco (27983)
      Automobile Driving Mistakes Cost Lives.
  • Not a new problem (Score:5, Informative)

    by JoshuaZ (1134087) on Sunday January 24, 2010 @06:11PM (#30882802) Homepage
    Bad software combined with poor training is not a new problem. In fact, one of the most famous serious failures of medical radiation technology. The most famous example is the Therac-25 debacle in the 1980s http://en.wikipedia.org/wiki/Therac-25 [wikipedia.org] which caused multiple deaths. In that case, a combination of bad software design (leading to race conditions), bad hardware interfaces and training issues combined to create a perfect storm of bad conditions. This appears in textbooks. Problems like this shouldn't still be happening.
    • Human error happens in programming and in medical procedures. It cannot be 100% eliminated until robots are programming robots. There can be addtional efforts taken to produce quality software such as more testing, more software/hardware interlocks, formal methods to prove systems, etc. .Better traning and maybe other things like actually evaluating the techs and MDs and firing the ones who screw up more than average could help. Medical care is under intense pressure to do more with less and thus the tec
    • by SuperBanana (662181) on Sunday January 24, 2010 @06:38PM (#30883034)

      This appears in textbooks. Problems like this shouldn't still be happening.

      They happen because the entire medical system is flawed; look at where many of the errors occurred. They had nothing to do with software. If the radiation shield/guide isn't installed, that's not the software's fault. Don't blame human problems on technical things, and don't solve human problems with technical solutions. If a nurse forgets to put a radiation shield in place, FIRE THEIR ASS.

      How flawed is the medical system in the US?

      • Doctors are trained by making them work the really shitty hours the older, more experienced doctors don't want to work- and working them to the bone (because they're paid a fixed salary, which is a pittance for the hours they're putting in) so that they're sleep-deprived. Which is know to interfere with judgment and decision-making processes. Perfect for diagnostic thinking, right?
      • Doctors can't be bothered to PRINT clearly on prescription slips, so pharmacies often fill the prescription out incorrectly, or have to call and pester the doctor- who probably doesn't remember what they wrote, and saw so many patients, that they don't remember correctly.
      • Doctors and surgeons routinely fuck up on the most basic things, like which side of the body they're operating on, often in some VERY serious, permanent operations, like amputations.
      • Doctors and nurses, time and time again, have been shown to not practice the most simple procedures for infection control, like washing their hands before/after every patient.
      • A couple of doctors in the Boston area have a)left patients on the operating table (opened up!) to run an errand at the bank b)shown up drunk or high for operations c)been beyond unprofessional to staff 'below' them (screaming, throwing things etc.)

      These are people who are some of the most highly paid people in society, who have taken an oath (which the are happy to get uppity about whenever it serves them.) When they fuck up, their malpractice insurance covers the lawsuit. And then the doctors turn around and bitch at us about how expensive it is to be a doctor, mostly because of their insane malpractice insurance.

      Did I mention that everyone goes into obscure specialties, meaning that if you want a Toe Oncologist, you can see one in a few days, but you've got to wait weeks in most major cities for a general practitioner...who just so happens to be the only person who can approve your care if you're on an HMO?

      • Ok, I'm responding to a troll, I know. But here goes. The post has a core of truth, but like all Slashdot-postings the "It's so simple I could just figure it out and do better" high-school naivety predominates.

        >Doctors and surgeons routinely **** up on the most basic things, like which side of the body they're operating on, often in some VERY serious, permanent operations, like amputations.

        - I have done thousands of operations and never a wrong-side operation. It is something that is taken *ex

        • by iamhassi (659463) on Sunday January 24, 2010 @08:29PM (#30884078) Journal
          Ok I'm wasting my mod points to respond to this because it needs a response. If you are truly in the medical field and work your a$$ off every day then you should be excited every time you hear a doctor is being sued for malpractice. We need to get rid of bad doctors. These patients are people, living breathing people, not cars that will be scrapped someday or can be replaced for a few grand. There is no excuse for mistakes. Equipment that can kill or maim should be double and triple checked. The nytimes article had an example of a women that was overdosed for 27 days. 27 days! There is no excuse for that.

          Now I understand the nytimes article you posted about a lawsuit where supposedly the doctor did no wrong but lost his practice anyway, there are families that will sue doctors no matter how excellent the care was, but you can't have it both ways, you can't have a perfect system where only the bad are punished and the good are rewarded. Like the saying goes, "If you want to make omelets, you have to crack a few eggs"

          I hope to god these doctors and hospitals were sued into non-existence. "Oops, my bad" works when you spilled the milk, not when you killed someone.
          • Again, ridiculously simplistic analysis.

            >you should be excited every time you hear a doctor is being sued for malpractice.

            You have got to be kidding; that statement is simply ludicrous. I don't engage in some sort of weird schadenfreude when somebody gets sued, even if it were somewhat legitimate. Medical school is relatively difficult to enter, selects for the most driven people, and is a long process where several dozen people work with you and gauge your progress and abilities. *OF COURSE* bad doct

            • lots of checklists will cut down on mistakes at all levels.

              There is a recent book on this; i forget the name. the results are huge i think it was 46% decrease in post op complications or something like that. (this isn't my topic of interest) Everybody has a bad day, a checklist is constant. I can't believe this wasn't common practice already (until that book.) It made so much sense for me when I was flight training... big planes are complex and 1 mistake out of order can be hard to fix in time.

              Simple sol

              • Checklists, etc. (Score:4, Interesting)

                by neapolitan (1100101) on Sunday January 24, 2010 @10:36PM (#30885172)

                Probably a lot of books written on it -- Atul Gawande did a pretty big "study" with safety checklist prior to OR activation. We have several checklists (independent of anesthesia) before starting any invasive procedure, so this is kind of behind the times. It is more targeted at foreign hospitals or places that have a lot of mid-level providers that are not used to things. If you are interested, the full study can be found here:

                http://content.nejm.org/cgi/content/full/NEJMsa0810119 [nejm.org]

                gbutler69 writes:
                >Says who? Citation Please?
                [snip a bunch of rhetorical questions]

                From your questions I infer you are completely out of touch with this field in any sort of form. If you want a citation, do a tad of research on your own and you will discover things; I won't spoon-feed.

                Poke around here to start (but some of this might be biased the *other* way.) Do a good deal of academic reading and you will get a good feel of what is going on:

                http://www.sickoflawsuits.org/ [sickoflawsuits.org]

          • by tomhath (637240)

            Get rid of bad doctors? Yes. Expect the rest of them to be 100% perfect across millions or billions of procedures a year? Unrealistic.

            First and foremost a patient has to be responsible for their own care. If you think something might be wrong, speak up! If you don't trust your doctor, find someone else! If you think you'll get better care in another country, don't hit yourself with the door on the way out!

            • You speak up. They dismiss you explaining that that is not the way it is done. Who are you to argue. They're the doctor. Oh, but, don't hold them responsible if something goes wrong. After all, what they do is so completely, absolutely complicated that mistakes will happen. So suck it up and die schmuck!
        • I can almost feel your frustration at being an expert in a crowd of Slashdot self-appointed experts. Thanks for the post and insights.
        • bravo (Score:3, Interesting)

          by SuperBanana (662181)

          - I have done thousands of operations and never a wrong-side operation. It is something that is taken *extremely* seriously, and we have at least three checks that guard against this. With over a billion procedures done per year, yes, there will be many that make the news, not unlike planes taking off on the wrong runway, etc., etc.

          And yet, despite all those checks, surgeons still fuck it up. And of course, why were all those checks necessary in the first place? Answer: incompetent, arrogant surgeons

      • by fuzzyfuzzyfungus (1223518) on Sunday January 24, 2010 @07:08PM (#30883284) Journal
        Blaming software isn't the answer(outside of specific software bugs); but blaming humans, while fun and morally satisfying, is also dubiously useful from the perspective of the system as a whole(this does not, of course, mean that you should feel any compunction about sacking egregious cases).

        For instance: The radiation shield/guide setup. Yeah, the nurse should have installed it, and she fucked up. However, it is a basic fact of humans that all of them fuck up from time to time, some more than others, and more under some conditions than others. Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the system as a whole very much. Instead, such safety critical systems should be designed to take human error into account. Routine use of checklists, for instance, has been demonstrated to reduce human error. Or, for the more high tech approach, the Radiotherapy machine could have a few extra sensors(RFID and optointerrupters) and the shield and guide units could be RFID tagged. If the machine does not detect the presence of the correct guides in the correct locations, it alerts the operators and refuses to provide a beam.

        Humans are flawed, often annoyingly so; but they are what we have to work with. Luckily, it is possible to systematically characterize the form of flawedness exhibited by humans(eg. limits of short and long term memory, probability of making an error on a procedure of given complexity as a function of experience, and so forth) and design systems that, as much as possible, are resistant to those errors. This requires a combination of organizational changes(eg. control of working hours, verification of nonimpairment for critical staff, enforced use of checklists and procedures, firing atypically unreliable staff) and technological changes(substitution of highly reliable barcodes/RFIDs for unreliable handwriting, automated sanity checking, marking patients before surgery, machines that refuse to operate unless their interlock conditions are met, etc.)

        Some of this is just a matter of time, some of it will piss off doctors, and some of it will probably piss off patients; but building reliable systems is possible.
        • by systemeng (998953)
          The therac 25 incident also involved a lack of interlocks. The previous model to the therac 25 had hardware interlocks which would never have allowed the shutter to stay open the way it did in the incident. Management got rid of these interlocks as a cost cutting measure. If these guys have designed another machine with no hardware interlocks, somebody needs to get fired.
        • by anorlunda (311253) on Sunday January 24, 2010 @08:28PM (#30884070) Homepage

          The article mentions that safeguards and procedures were ignored. Before calling for new rules, new procedures, new designs, it would be wise to force existing safeguards to be used without exception.

          Perhaps a conviction or two for negligent homicide against the doctors, nurses, administrators and vendors might get their attention.

          • by drinkypoo (153816)

            The article mentions that safeguards and procedures were ignored. Before calling for new rules, new procedures, new designs, it would be wise to force existing safeguards to be used without exception.

            Yes, that's precisely what the GP said; he's talking about a safety interlock, which is a technical means to force the use of existing safeguards without exception. The simple truth is that a policy is not enough when human life is at stake and the technical means to avoid the problem exist. The hardware and software should cooperate to absolutely prevent workers from being able to bypass safeguards.

        • Re: (Score:3, Interesting)

          by iamhassi (659463)
          "Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the system as a whole very much. Instead, such safety critical systems should be designed to take human error into account."

          Maybe prosecuting her for murder would help reduce human error? Do you think saying "humans are flawed, deal with it" helps?

          Unfortunately there is no system that can eliminate human error, and I'm sure at some point the nurse was told "make sure t
          • The reason that I don't think that cracking down on the individual who happens to make the error(again, unless they are clearly negligent or malicious about it) will be of much use is the example of occupational safety.

            Among industrial workers who deal with big, self-evidently dangerous, machinery(watching an industrial punch or something forming steel should make inferring what it'll do to your hand trivial for even the thickest among us), humans still err from time to time. Even when the penalty is ins
        • by mjwx (966435)

          Blaming software isn't the answer(outside of specific software bugs); but blaming humans, while fun and morally satisfying, is also dubiously useful from the perspective of the system as a whole(this does not, of course, mean that you should feel any compunction about sacking egregious cases).

          I think your post boils down to "blaming is not the answer".

          Humans do screw up. What's important is that when humans do make mistakes that the situation is rectified so that mistakes do not happen in the future. T

          • Just where the fuck did this idea come from? Who the fuck is selling this? Who the fuck is buying it?

            Everyone wants to say this until they are the victim of someone else's mistake. If I drive too fast for conditions and I slide on the ice and wreck my car into your livingroom and kill your children, then I shouldn't be blamed. It was just a mistake. We should just work on better protocols to help keep me from doing this in the future. Maybe we can make the cars have ice sensors (temperature/humidity etc)

            • Just where the fuck did this idea come from? Who the fuck is selling this? Who the fuck is buying it?

              Did you even read my post. I know it's incredibly pretentious quoting myself but seeing as you cant read.

              this also means that some responsibility must also be taken but pointless finger pointing helps no-one and fails to fix the issue.

              Responsibility != blame. Blame is cast, responsibility is taken. The point of my post (that you so conveniently missed with your inaccurate rant) is that a mistake needs

              • by gbutler69 (910166)

                This implies two things, 1. you knew that your chose speed was not sufficient for the conditions and 2. you still chose to drive at that speed.

                No, it implies no such thing. I could believe I was driving at a safe speed all I want, but, the fact that I wrecked means I was driving too fast for conditions. You are the one mixing things up. You insist that a driver who makes a mistake is Negligent, but, a health practioner who makes a mistake merely needs to take responsibility. What do you even mean? You make no sense.

                • by mjwx (966435)

                  No, it implies no such thing.

                  Yes it does, you chose to drive at a speed that you knew was unsafe for those conditions.

                  I could believe

                  This is why we have laws that regulate speed, sometimes this changes according to road conditions, land zoning or other considerations.

                  the fact that I wrecked means I was driving too fast for conditions

                  Now are you trying to tell me you were "accidentally" driving too fast for conditions? Did you pass your driving test? This is not an accident.

                  You insist that a driver who

                  • You are completely ignorant. How does someone "Choose to drive at a speed that they knew was unsafe for conditions if the believed they were traveling at a safe speed?"

                    Then you say, "This is why we have laws that regulate speed, ..." Yeah, and we also have laws that regulate medical safety. So what the fuck is your goddamn point?

                    "Did I pass my driving test," you say. Did you pass your medical exam? What's the difference?

                    With your terrible example you are expected to know how to perform a medical proce

              • Negligence has nothing to do with deliberate.
                Negligent Neg"li*gent, a. [F. n['e]gligent, L. negligens,p.
                pr. of negligere. See Neglect.]
                Apt to neglect; customarily neglectful; characterized by
                negligence; careless; heedless; culpably careless; showing
                lack of attention; as, disposed in negligent order. "Be thou
                negligent of fame." --Swift.
                [1913 Webster]
                • by mjwx (966435)
                  Re read that definition and tell me that one can be negligent without being deliberate.

                  Once again you lack a clue. Negligence in a legal sense is when one fails to take precautions that they know they should. This makes it deliberate. Here is a short definition of medical negligence [sa.gov.au] from a South Australian legal service, negligence is failing to take reasonable care.
                  • I think you lack reading comprehension. Failing to take reasonable care is not the same thing as deliberate. You just proved my point. You so want to believe that a medical mistake is not negligence, that you will twist words to mean what you think they should mean rather than what they in fact mean. I feel like I'm arguing with Bill Clinton over what the meaning of the word "is" is.
              • Where is "Deliberate" or "On Purpose" in any of that? Now I see why health practioners object to lawsuits. They don't think they are negligent because they don't even know what the goddamn word means! Syn: Careles; heedless; neglectful; regardless; thoughtless;
                indifferent; inattentive; remiss.
                [1913 Webster]
        • Yeah, the nurse should have installed it, and she fucked up. However, it is a basic fact of humans that all of them fuck up from time to time, some more than others, and more under some conditions than others. Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the system as a whole very much. Instead, such safety critical systems should be designed to take human error into account. Routine use of checklists, for instance, has

      • Hollywood upstairs medical college is like that and the dockets where wow dates by getting them any (drug) that they want.

      • Did I mention that everyone goes into obscure specialties, meaning that if you want a Toe Oncologist, you can see one in a few days, but you've got to wait weeks in most major cities for a general practitioner...who just so happens to be the only person who can approve your care if you're on an HMO?

        Pay for a GP-- now usually called a Family Practitioner or General Practitioner or Internist -- sucks compared with specializing. And medical school costs the same regardless of specialty. Major financial disincentive (at least in US). You'd think the shortage of GPs would result in higher pay -- free markets and all -- but it doesn't seem to be working in the short run.

        I know what you're writing about. My wife is a first year resident in family practice. One of her responsibilities is clearing patient

    • Re: (Score:3, Informative)

      by RDW (41497)

      The NYT article mentions Varian treatment planning software. Looking at a recent safety warning:

      http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/FieldSafetyNoticesformedicaldevices/CON068203 [mhra.gov.uk]

      it seems that, as in the case of the Therac-25, an unexpected sequence of user inputs (in this case 'removing the Primary Reference Point...prior to performing planning approval') can under certain circumstances cause an error ('the resulting calculated dose may differ significantly from the origin

    • This appears in textbooks.

      It also appears in non-fiction books [reviewsonline.com] about this type of problem.

  • This is scary... (Score:2, Insightful)

    by xQuarkDS9x (646166)

    This is scary indeed when you are under the assumption that you are going into a hospital or clinic for a treatment like this, and assuming he/she is well trained and know what they are doing to your body... to read something like this makes one wonder just what, if any training they get to operate these machines?

    How did one guy above me put it... Highly trained morons? I have to agree!!!

  • Therac-25 (Score:5, Informative)

    by slimjim8094 (941042) <slashdot3@justconne c t e d . n et> on Sunday January 24, 2010 @06:13PM (#30882824)

    http://en.wikipedia.org/wiki/Therac-25 [wikipedia.org]

    Famously killed 2 people as a result of radiation poisoning. It's also a case study in software design - the software was reused on a model without hardware interlocks; this allowed the machine to get into an inconsistent state where it would deliver something like a hundred times the intended dose.

    You'd think people would've learned.

    • Re: (Score:2, Insightful)

      by mysidia (191772)

      People did learn...

      And then they got laid off, and replaced with outsourced development companies from India, who haven't learned yet, or just don't care as much.

      • Re: (Score:3, Insightful)

        by Cryacin (657549)

        outsourced development companies from India, who haven't learned yet, or just don't care as much.

        Unfortunately, it's the latter and not the former. And by the way, it's not "India" that is the problem, but "outsourcing company". I have worked with some fantastic Indian developers, but they don't work for outsourcing companies. "Cheap" outsourcing companies are not good at developing software, they are experts in sending out invoices.

  • by Protonk (599901) on Sunday January 24, 2010 @06:14PM (#30882836) Homepage
    Therac-25 [wikipedia.org] is only the most prominent medical radiation incident from the past 20 years or so. The IEEE linked at the bottom explores problems with replacing hardware interlocks (mostly literal interlocks) with software interlocks, which fell prey to memory errors, bugs and human intervention. Tools like this require constant diligence and skepticism, which is nearly impossible to maintain when faced with incentives to update, promote and distribute new technology. I suspect this will devolve into some meta-discussion about regulation, but look closely at the allegations regarding cover-ups in the Therac-25 case and this article--market response presupposes that customers and investors are informed about errors in products. Where companies downplay or obfuscate errors of this magnitude, public choice [wikipedia.org] fails. Regulatory bodies won't work perfectly, but I suspect that their intervention in the market would reduce these errors at some high but acceptable cost (in either monetary terms or terms of new technologies forgone due to the cost of compliance).
  • ...such as the Therac-25 malfunction [wikipedia.org] that is the textbook case of how poorly-designed UIs can have catastrophic repercussions. The Nancy Leveson article [mit.edu] cited is a fascinating read. It is required reading for my advanced computer science students.

  • by MichaelSmith (789609) on Sunday January 24, 2010 @06:16PM (#30882852) Homepage Journal

    The whole point is to kill part of the body but a lot of the time this involves almost killing the rest of the body. My wife's father died because he had a rare sensitivity to a chemotherapy drug. They kept going back to the hospital and saying "it feels like this is killing him" and the hospital people would say "yes, that's normal, everybody thinks that". And by the time they realised it really was killing him he had no bone marrow left at all, which is fatal. In that case the problem could have been identified if more people were on the ball, but in practice they are just doing their jobs, going through the motions.

    Its a bit different in technology. Normally when you (say) shut down a server you can check which server you are shutting down first and triple check it. Sure, if data has been left in a machine and you didn't check then thats a problem. But more commonly in medicine its a case of "lets try this, it might work" with no opportunity to check along the way.

  • by dorpus (636554) on Sunday January 24, 2010 @06:17PM (#30882868)

    These numbers don't mean anything unless we know how many procedures are conducted in total. It could be that the probability of a fatal complication, defined as (# of fatal complications) / (# of procedures) is quite low.

    I took a course on clinical decision analysis last semester. Every intervention, even diagnostic ones, carry a risk. The risk needs to be weighed versus its benefit to determine its overall efficacy. If the patient is very ill and has a short life expectancy or very low quality of life, then even dangerous procedures become acceptable.

    One can conduct analyses based on expected life expectancy, QALYs (Quality-Adjusted Life Years), QOL (Quality of Life), or from a purely economic point of view. How much is a patient's life worth? Is a 5-year-old's life worth more than an 85-year-old's life? What about a 45-year-old? This can get quite philosophical. One could even conduct an analysis against a combination of outcomes, though how we choose to weigh the different outcomes is arbitrary.

    Bayesian probabilities figure heavily into these analyses, and they can give quite counter-intuitive results. For example, if a test for AIDS is 99% "accurate" (in terms of sensitivity and specificity), it can still have a very high false positive rate (if AIDS is rare in the general population). In this sense, the AIDS test carries a toll of emotional devastation for the false positives. It can be a challenge to convince the general public, even your average physician, of the validity of a model. A good model will have conducted sensitivity analyses to allow for the possibility that a given procedure may have a higher (or lower) risk than expected.

    • Is a 5-year-old's life worth more than an 85-year-old's life? What about a 45-year-old? This can get quite philosophical.

      Yeah, especially if you think that utilitarianism is the only moral philosophy. Some of us think that the moral cost of removing a person's only functioning kidney is rather more than the economic cost associated with their death.

    • "It could be that the probability of a fatal complication, defined as (# of fatal complications) / (# of procedures) is quite low."

      It doesn't matter how low the numbers are, anything above ZERO mistakes is BAD, period! We're not talking about the risks of radiation therapy here. We're talking about the risks of IDIOTS FUCKING SHIT UP! These people didn't die because the radiation didn't work, they died because some dipshit didn't use the machine correctly. It's the same thing as a surgeon cutting out so
      • by dorpus (636554)

        If you can think of a better way to treat cancer, feel free to propose a new treatment. It might take degrees in oncology, statistics, epidemiology, biochemistry, etc. before you know what you are talking about, though. Also, the treatment must have a reasonable cost; a billion-dollar treatment will not be practical for anyone.

  • Linear accelerators have contributed to saving far more lives than these errors have taken. Fortunately, these kind of errors are comparatively rare and not the menace to health that the summary leads one to believe.

    • Re:perspective (Score:5, Insightful)

      by Jaime2 (824950) on Sunday January 24, 2010 @07:36PM (#30883570)
      What's important here is that it isn't an either/or scenario. We can fix the underlying problems without abandoning radiation treatment. The much quoted in this thread Therac-25 incidents are part of why this problem hasn't been solved. Twenty years ago, someone sold some radiation treatment equipment run by horribly designed and poorly debugged software. Two people died and everyone involved knew why within a few years. However, no person nor company was ever punished. No real rule changes were made. Given the history of this industry, these new events are unforgivable. It's not that hard to put some practices and regulations in place that will only add five to ten percent to the cost of the treatment and will drastically reduce these "negative patient outcomes caused by preventable circumstances".

      Heck, Therac-25 is the freakin' case study that people use to learn about the possible consequences of bad software design. You'd think somebody at the FDA would have heard of it and made some sort of link to the work they were doing before approving the successor to the Therac-25.

  • Human Error (Score:5, Insightful)

    by devnullkac (223246) on Sunday January 24, 2010 @06:30PM (#30882990) Homepage

    Although the mistakes were largely due to human error, buggy software also played a role.

    Not to put too fine a point on it, but buggy software is also human error.

    • The difference is that it's not a human error that anyone at the end of the line can fix. The radiation tech can't go reprogram the machine to fix someone else's "human error".
  • Dangerous treatments are more dangerous than normal treatments, all around. For example, if someone presents with an uncomplicated infection, you prescribe them antibiotics. Let's say a five day pack of zithromax, also known as a Z-Pak. There are several ways this can be dangerous. For example, if you didn't ask them if they were allergic, they could turn out to be. Or if they didn't know they were, so they said no. Or if the pills in the pack are actually something else. Or if there's a misdiagnosis

    • Re: (Score:2, Funny)

      by jhoegl (638955)
      Yes, I too blame pregnant women for overworked coworkers and thus excuse any mistake they make, including death.
      • by Renraku (518261)

        I'm just saying that there are a variety of conditions that can affect the variety of conditions that your treatment is under. Maybe your MRI was misread or mislabeled. Every step between diagnosis and treatment adds one more layer of complexity between you and the cure.

  • Test Every Time (Score:4, Interesting)

    by MBCook (132727) <foobarsoft@foobarsoft.com> on Sunday January 24, 2010 @06:49PM (#30883120) Homepage

    Is there some reason they aren't required to put a radiation probe of some kind on the patient for each treatment, to double check they are getting the prescribed dose?

    Wouldn't that prevent all these accidental overdoses, so the only people who suffer are people with doctors who accidentally prescribe 1000x the normal dose because they're idiots?

    Surely the savings in catching these things early and the malpractice cases that come out of it would be cheaper then when you burn giant holes in peoples chests from overdoses and don't even have the brains to realize what happened.

    • by CmdrPorno (115048)

      It seems logical that the machine should have some sort of sensor on it to verify the amount (and physical pattern) of radiation given. Set up like this, you could even do a test run of the treatment with no one in the room in order to be certain that it was doing what you intended.

    • There are detectors that signal to the operator the dosage the patient was actually exposed to. Unfortunately the 'technician' did not notice the warning on two separate occasions.

    • It's much cheaper to settle with the families with gag orders attached.

      Gag orders should not legally be allowed in settlements. The ONLY reason they're used is to prevent justice.
    • What surprises me is that the treatment was continued after the system appeared to be misbehaving. I work with a large (the world's largest actually), linear accelerator. We do not do medical work, but do have various radiation safety systems. When a safety system behaves in an unexpected fashion, the operators do no just "try again". The affected part of the system is shut down and the problem is investigated by experts. I have observed this in person and it appears to me that the operations staff takes t

  • The problem here. (Score:5, Insightful)

    by DavidTC (10147) <slas45dxsvadiv D ... neverbox DOT com> on Sunday January 24, 2010 @07:08PM (#30883298) Homepage

    While, as nerds, everyone here leaps to 'computer error'(And everyone mentions that Therac-25 disaster we all learned about in comp sci 101.), computers aren't really responsible for a brain cancer patient getting treatment for breast cancer.

    A computer might say where to aim the machine, but someone who was even slightly familiar with the case would say 'Um...the breasts? No, that can't be right.'.

    What is responsible is the constant reduction in the amount of staff at medical facilities, and consequently, the inability for any actual checking or familiarity with patients.

    Read the horrific description of what happened to Jerome-Parks, please notice that it was people trying program crashing machines, machines that were obviously screwed up, and no one bothering to actually look at the result. And then doing it twice more because no one bothered to look into the obvious mistake.

    Essentially, the problem here isn't the Therac-25 one, where a shitty user interface resulted in the screen saying one thing and doing another. Note that in every described situation, the machine clearly described what it was doing. It wasn't 'doing something else besides what it said', it was doing what it had, incorrectly, been told to do. It said it was doing it, it did it. The machine worked perfectly.

    It is equivalent of being a newspaper reporter, and Word crashes while I save my article...but I submit it anyway, and the front page of the newspaper is filled with gibberish. You know whose fault that is? Sure as hell not Word. It's my fault, it's the editor's fault, it's the guy doing the final check before the print run. If I were to claim the solution to this constantly happening was 'crash-proof software', I'd get laughed out of society.

    Oh, but newspapers actually, you know, pay people to check that before spending thousands of dollars doing a print run. If only someone's life was worth more than that.

    Yes, we can argue the machine should have fail safes to stop them from working in obvious stupid situations, but this just stops obviously stupid situations, and only overdoses. What is that is a perfectly reasonable dose...aimed at entirely the wrong spot, for someone with an entire different type of cancer?What if it's 100x what you should be getting, but still within the bounds of reasonable for certain extreme types of cancer? What if that is, in fact, practically no dose at all, so you die of a fucking treatable cancer because you got not treatment?

    More to the point, why are we worried about this, when drug errors kill ten thousand times as many people? (Because machines often do have failsafes, unlike prescriptions.)

    If only we had a system where all the money wasn't sucked out of the system by insurance companies, one where we actually paid to have competent medical staff who could actually watch what was going on, instead of spending ten damn seconds a patient.

  • Two fatalities? In 8 years? And we are talking about rather intensive procedures for which informed consent is obtained either directly or by proxy?

    If we're going to stick to a medical scene, how many fatalities due to surgical 'mistakes' occurred? Drug related accidents too. Either makes the 'two' look like Disney material.

    During the same period NTSB general aviation (ie not commercial airlines) reports show 181 incidents, 147 accidents, 109 fatalities in the US.

    For commercial accidents and fatalities, go

  • by DaneM (810927) on Sunday January 24, 2010 @07:40PM (#30883616)
    I have a friend who recently was laid off from a smallish Fresno, CA-based company (I think it was Fresno...) that makes computers and software for radiation dosing and administration. Apparently, the owner of the company bought it from the previous owner, who in turn had purchased it from the original owner. The original owner sold it some 20 years ago, and in the shuffle of ownership, all of the people who actually wrote the original code (which was buggy to begin with) were lost. So, for the last 20 years or so, the company has been trying to "band-aide" software that they don't really understand themselves. Essentially they were one of the first companies to come up with software for the treatment of radiation, but due to bad ownership and terrible business decisions (such as firing all the employees that know what they're doing, because it costs them too much in payroll), they've basically been relegated to servicing poor hospitals and nations who can't afford anything better. Personally, if I were to get radiation treatments, knowing what I've heard from an inside source, I'd very much want to research the companies that make the software and hardware that I'll be at the mercy of. That, and not go to a poor hospital that can't afford the good stuff. $0.02 Cheers!
  • by jimicus (737525) on Sunday January 24, 2010 @07:49PM (#30883720)

    My wife is a therapeutic radiographer - not that this means I'm qualified to understand it, but it does mean I hear of some of the incidents.

    Radiation therapy is potentially dangerous. So is all cancer treatment - the reason we use it is because it's a sight less dangerous than letting nature take its course. The main solution is a combination of two things:

    • Machinery which won't let you make the most obvious screwups like putting an extra zero into the dosage.
    • Processes which involve double and triple checking every step of the way. These processes are followed religiously.

    However, neither of these are foolproof. The machinery has to be calibrated - it doesn't magically give out the correct dose when told to when it leaves the factory. Calibration errors have caused people to receive much higher doses than intended - and usually the first you hear about it is when a patient complains of significantly worse side effects than you were expecting significantly earlier. Other times patient errors have very nearly resulted in the wrong treatment altogether.

    Patient errors? Yep, it can happen. Two patients with a similar name in the waiting room, the next patient is called for and the wrong person gets up. You're supposed to check the patients' date of birth every time but a lot of people seem to lapse into just nodding and agreeing with everything the person in uniform says, so if the patient is asked "Is your date of birth 1st March 1960?" (rather than "Can you confirm your date of birth for me please?"), they just mindlessly agree. My wife's suggestion to help reduce this risk was that photographs of patients be taken on their first treatment and kept with their records - frankly, the only amazing thing about this is it was 2009 when it was made and it wasn't standard practise.

    Paradoxically, one of the ways errors are dealt with is to instigate a firm "no blame" policy. The reason for this is so people aren't tempted to try and cover up errors.

  • I had the radiation oncologist review the status of every single treatment with me face to face 41 times.

  • by Wyatt Earp (1029)

    Had radiation go wide during a 6 day cycle, radiation burns and good times. It was picked up the following cycle and "adjusted" for.

    • by maxrate (886773)
      I'm truly sorry that happened to you. Reading this article made me feel incredibly horrible for anyone negatively affected due to computer malfunction and/or operator error. I hope you are well.
  • by rbanzai (596355) on Sunday January 24, 2010 @08:52PM (#30884244)

    ... and stuff like this makes me anxious. I had 30+ zaps to my leg. Initially there was a rather involved simulation to precisely aim the beam. They made a mold to hold my leg in place for the treatments and tattooed targeting dots on my leg.

    They screwed up. It was completely bungled and part of the beam was aimed to go right down the side of my leg, frying the top layer of skin. Within a couple of treatments they adjusted it and just used sharpies to make new targeting dots.

    One day I was lying on the table with my balls in the lead sphere to protect them when over the PA I heard the old Windows error sound. Scared the crap out of me until they told me they only used Windows for their scheduling software.

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