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Radiation Therapy Mistakes Cost Lives

kdawson posted more than 4 years ago | from the feel-the-burn dept.

Medicine 215

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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highly trained morons (5, Informative)

timmarhy (659436) | more than 4 years ago | (#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.

Re:highly trained morons (5, Insightful)

Jophish (1489121) | more than 4 years ago | (#30882912)

Alternate title: Radiation Therapy Success Saves Lives

Re:highly trained morons (3, Interesting)

Zerth (26112) | more than 4 years ago | (#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! (3, Insightful)

bussdriver (620565) | more than 4 years ago | (#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.

Re:CHECKLISTS! (0)

Anonymous Coward | more than 4 years ago | (#30884716)

There are benefits to checklists, but they need to be performed by competent people. I work in Operations at a nuclear power plant. We have tons of checklists, but we also recognize that they are only an operator aid. They don't take away our responsibility to actually know what is going on. This works because we are competent and understand plant status at all times. But if you give a checklist to someone who is incompetent and doesn't understand the status of the equipment that he or she is operating, then you are going to have a problem. Instead of being considered an operator aid, the checklist will be considered a justification or a transfer of responsibility for safety. And when that happens, I guarantee that mistakes will occur. I've seen too many people outside of my field use them this way.

Re:CHECKLISTS! (2, Informative)

qohen (104310) | more than 4 years ago | (#30884748)

Background on medical checklists saving lives (and yet meeting up with resistance at times from medical practitioners) in this important New Yorker piece by surgeon/writer Atul Gawande:

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all [newyorker.com]

Gawande now has a book out about checklists called "The Checklist Manifesto: How to Get Things Right" that expands on this and also describes the usefulness of checklists in other areas: http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0805091742 [amazon.com] (If the topic interests you, btw, Amazon apparently is selling this $24.50 hardcover book for only $10).

Re:highly trained morons (0)

Anonymous Coward | more than 4 years ago | (#30883066)

You mean that in America people are treated by carrots* in lab coats?!?
No wonder so many mistakes are made in your hospitals!!

*stick that in an English-Welsh translator and you shall see what I mean.

With love,
The Anonymous Coward

Yeah, I know. (5, Interesting)

gbutler69 (910166) | more than 4 years ago | (#30883408)

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!

Re:Yeah, I know. (-1, Flamebait)

Anonymous Coward | more than 4 years ago | (#30883850)

Whilst I sympathise, you're being rather melodramatic.

People survive perfectly well on one kidney.

And if the US adopted a socialised healthcare service, you wouldn't have had to pay a thing.

Melodramatic? (3, Insightful)

gbutler69 (910166) | more than 4 years ago | (#30883980)

People survive just fine with one arm? People survive just fine that are blind? People survive just fine who can't hear? People survive just fine with a permanent colostomy bag? People survive just fine with their tongue cut out? People survive just fine with one leg? People survive just fine with their face melted off with acid or burned off in fire? People survive just fine with their testicles mistakenly removed? People survive just fine with their dick cut off? People survive just fine without a bladder of any sorts?

You're welcome to accept any of these conditions any time you want jack-ass!

Re:Yeah, I know. (1)

w0tan (1723966) | more than 4 years ago | (#30884052)

So glad you have it all figured out. Who cares that some third world affirmative action hires are bugling their way into organ failure and negligent deaths. Not your problem, let the 'gubmint' sort it all out right? Big brother knows best. Better yet, if you can take yourself away from your marxist ivory tower for a moment, how about you put your money where your mouth is and give up one of your kidneys to someone who needs it. Maybe like this poor mans Wife. Then again it's tough to actually care about someone or something in the real world, and still live in the world frankfurt school style delusion. I see why you abdicate your duty to Big Brother: it costs you nothing to get you fix of self righteous delusion.

Re:Yeah, I know. (0)

Anonymous Coward | more than 4 years ago | (#30884216)

You're very deluded if you think the US healthcare system would pay for that.

Re:Yeah, I know. (1)

MobileTatsu-NJG (946591) | more than 4 years ago | (#30884034)

I wish you both the best.

Re:Yeah, I know. (1)

ffreeloader (1105115) | more than 4 years ago | (#30884460)

I wish you and your wife the best. I know from personal experience just how badly the businessmen, err, I mean doctors, in this country can screw up. My wife and I have both spent many thousands of dollars due to businessmen posing as doctors making mistakes due to arrogance and just flat out not caring for anything but the money they make.

It's difficult to find a competent, caring doctor these days.

Re:Yeah, I know. (1)

OldEarthResident (1724062) | more than 4 years ago | (#30884548)

You have my sympathy.

Here in NHS land, I have found the NHS to be good when faced with known conditions (especially when it's associated with one of the many targets they use internally), but they are far less impressive when faced with unusual symptoms.

I hope your wife gets well again.

Re:highly trained morons (0)

Anonymous Coward | more than 4 years ago | (#30884538)

I recently dislocated my right elbow. Went to the Dr for a followup and he noticed that whoever filled out the form said it was my left elbow. Was it dyslexia at work?

A few years ago, I was working on a mill startup with an electrician. He said they had an apprentice in their program who was red/green color blind. Since green is used for ground and red is commonly used for hot, he would get things mixed up. They suggested he resign, but couldn't do anything outright because of the Americans With Disability Act.

Windows as usual. (0, Troll)

Ethanol-fueled (1125189) | more than 4 years ago | (#30882756)

TFA:

When the computer kept crashing, Ms. Kalach, the medical physicist, did not realize that her instructions for the collimator had not been saved, state records show. She proceeded as though the problem had been fixed...

...Shortly after 11 a.m., as Ms. Kalach was trying to save her work, the computer began seizing up, displaying an error message. The hospital would later say that similar system crashes "are not uncommon with the Varian software, and these issues have been communicated to Varian on numerous occasions."

Surprise, surprise. A little link-jumping through the manufacturer's products [varian.com] and job openings reveal .NET on Win32.

Or could somebody prove that the machines themselves run Linux or some kind of other embedded OS?

Re:Windows as usual. (1)

jhoegl (638955) | more than 4 years ago | (#30883060)

The machines themselves run their own OS, but I dont know what it is based off of. Im sure it varies based on machine.

However, I can tell you that they port their information to a Windows client.

Therac had a similar failure mode on PDP-11 (1)

argent (18001) | more than 4 years ago | (#30883172)

I don't know what Varian uses, but the Therac incident involved an embedded PDP-11, probably running RT-11 or RSX-11.

Purely for trivia fans: RSX-11 was Dave Cutler's first OS, followed by VMS and NT.

Breaking news (4, Insightful)

rockNme2349 (1414329) | more than 4 years ago | (#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.

Re:Breaking news (0)

Anonymous Coward | more than 4 years ago | (#30882926)

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

Anything wrong with the technology, meaning the hardware? No. Anything wrong with the software used to drive the hardware? Yes. Anything wrong with the operators making mistakes due to not diligently checking the output of the software and not properly monitoring displays during treatment? Yes.

Having just read the article about an hour before it showed up here I did notice that the software used to program the treatment machine was prone to abnormal termination due to poor error handling. The software would offer to allow the operator to save the treatment data prior to termination. Apparently this could lead to incorrect/erroneous data being saved. If the operator didn't carefully check everything after reloading treatment data saved under such circumstances bad shit could happen. Bad shit like exposure to excessive radiation to more of the body than was needed eventually resulting in patient death after extended suffering.

So yeah I guess it does boil down to people were stupid. Coders were stupid, operators were stupid, people training the operators were stupid. Add some ignorance and carelessness to that and you end up with tragic results.

Re:Breaking news (1)

ThrowAwaySociety (1351793) | more than 4 years ago | (#30883822)

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.

Re:Breaking news (1)

Nyeerrmm (940927) | more than 4 years ago | (#30884376)

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 probably tens of thousands of uses. This doesn't suggest to me that the tech is flawed, but rather that its new. It suggests improvements in the way its run -- checklists, multiple operators with redundant procedures, improved UIs, and avoiding using it except when absolutely necessary -- but it doesn't imply that the tech needs to be done away with.

Re:Breaking news (1)

SEWilco (27983) | more than 4 years ago | (#30884496)

Automobile Driving Mistakes Cost Lives.

Not a new problem (5, Informative)

JoshuaZ (1134087) | more than 4 years ago | (#30882802)

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.

Re:Not a new problem (-1, Troll)

Anonymous Coward | more than 4 years ago | (#30883008)

Have you talked to a nursing student lately?

Majority of college girls I meet are in nursing major, yet their mental capability is that of a baby chimpanzee.

Most of them pick that major because it is "easy money".

I'm not surprised shit like this happens.

Re:Not a new problem (-1, Troll)

Darkness404 (1287218) | more than 4 years ago | (#30883168)

And of course, mix this in with more government involvement in health care and you have a recipe for disaster.

Re:Not a new problem (4, Interesting)

omglolbah (731566) | more than 4 years ago | (#30883494)

We have public health care in Norway and I see far fewer problems than in the US...

Re:Not a new problem (-1, Troll)

Darkness404 (1287218) | more than 4 years ago | (#30883630)

...And chances are your lawmakers actually read the fucking bill and not just trying to push it through without any regard for what people think.

Re:Not a new problem (1)

omglolbah (731566) | more than 4 years ago | (#30883688)

Well, that is an issue with the US two-party system that I dont want to touch with a 20 foot pole :-p

Re:Not a new problem (0)

Anonymous Coward | more than 4 years ago | (#30884188)

Socialism works in Norway because of your huge oil and gas reserve, other resources, good planning, small population and landmass, and fairly strict immigration regulations.

Don't think that just because it can work for one country means it can work for another. Point out a large nation with socialism that has worked quite well (UK is NOT large).

Of course, corporate socialism is even worse... but that's another subject for another day.

Re:Not a new problem (1)

twiddlingbits (707452) | more than 4 years ago | (#30883032)

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 techs are rushed or are backed up and overworked thus making mistakes. The software doesn't know this. It does what is asked. So you must correct many issues at the same time, better software, better training, better procedures, more techs, more Radiation Treatment facilities all of which cost more money. Too much costs and you go out of business, too many mistakes and you do as well. Catch-22.

most of the problems aren't technical (5, Interesting)

SuperBanana (662181) | more than 4 years ago | (#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?

Response to the "problems." (3, Informative)

neapolitan (1100101) | more than 4 years ago | (#30883232)

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 *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.

>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.

  - True again to a small degree, but everybody at my hospital does this. It probably could make a bit of difference if done nationwide, but again, this is taken extremely seriously.

>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.)

  - a) I was a resident at the very same major hospital when this happened. I know the inside story, and it was nowhere near as simple as it sounds.
  - b) ?? The MD would be promptly fired. I don't understand what kind of life you imagine we lead.
  - c) Yes, I agree this is a problem. This is a very big problem that the medical "culture" has some deficiency with. Equally bad is an antagonistic attitude by people "below" the MD who try to passive-aggressively sabotage things or "protect the patient" by alienating the rest of the staff. We need to work as a team, and at my hospital I strive to make sure that is always done.

> When the *** up, the malpractice covers the lawsuit.

Again, you have some sort of "fantasy" about M.D.s that is not remotely grounded. I'm guessing you wanted to go to med school and never had the wherewithal to go through with it? Or maybe had some unfortunate experiences as a patient?
  - Nobody, NOBODY wants to get sued. The idea that we just sit in a lounge and make patients wait, etc., is pure nonsense. I work my a$$ off every day, and my friends with similar education and ethic get paid twice what I do. I am far from "among the most highly paid in society."

If you want a realistic sense of what may go on during a suit, read this piece:
http://www.nytimes.com/2009/12/29/health/views/29case.html?_r=1 [nytimes.com]

Anecdotes, here and there (0)

Anonymous Coward | more than 4 years ago | (#30884000)

I'm not the GP, but... It is great that you (claim to) have high moral standards. It really is. But that most certainly isn't the case for all the doctors and based on my experience, I would claim that it might not even be the case with most doctors.

I personally have breathing problems. I can't give you the diagnose as I have never been diagnosed with anything. All I know is that I occasionally have great difficulties breathing and get exhausted easily. It's not about me being in bad shape either (I'm not athletic, but I'm 20 years old male with no extra weight. I shouldn't get exhausted from simply speaking). Breathing problems are a terrible thing to have: They affect your life, your mood, keep you up at nights, etc... Especially when you don't know why you have those.

I have seen doctors because of this. Many doctors. About a dozen, before I just gave up. None of them implied that these might be just in my head or anything like that (though perhaps two of them asked if I had stress, etc.) but most simply don't care enough to examine their patients that well. If it is some simple disease or infection that can be quickly diagnosed and treated, great. If it is something chronic? You are out of luck. Most doctors seem to care only about the current visit: If you go there, complain about breathing problems and they find nothing, they say "Okay, it's probably nothing to worry about." without caring about the fact that it's the 10th time you've felt like you really need to see the doctor about the problem.

Eventually I found a doctor that was willing to send me to tests about asthma and x-ray my lungs. The day I was x-rayed I had breathing problems again and the doctor also thought that it seemed as if I had some liquid in my lungs. She sent me to ultrasound to be sure but they found nothing (that day I also had no breathing problems) so that was it then, no diagnose again. At that point I just gave up even trying and decided to live with it.

I hear ya brother. (1)

gbutler69 (910166) | more than 4 years ago | (#30884080)

I have a very similar problem. Chronic issues with breathing and nasal irritaion and pain. Stomach irritation and pain. Nothing seems to help. I had severe Asthma as a kid, so was diagnosed. Used to be highly allergic to just about everything. Supposedly, I outgrew those allergies, but, really all I did was outgrow such a strong reaction to them that I'd need to be hospitalized and put on oxygen or die. Now, everything is just pain and struggle to breather, but, hey, I'm alive. I should be thankful, right? Doctors don't know anything to help me. I gave up. It's not really their fault, they just don't really know that much about these kinds of conditions period. It sucks. But, it's noones fault.

Wish I had some answers for you. Maybe, since you are so young, that soon they'll figure some of these issues out and you won't have to live for 40 years with this problem. Here's hoping.

Re:Response to the "problems." (4, Informative)

iamhassi (659463) | more than 4 years ago | (#30884078)

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.

Lawsuits are a very dull edge (2, Interesting)

neapolitan (1100101) | more than 4 years ago | (#30884196)

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 doctors need to be stopped, just like "bad pilots" or "bad computer programmers." Indeed, a lawsuit is one of many ways, in fact a poorly targeted way, of doing this. There are many other options including board registration, hospital credentialing, and outcomes monitoring. Life is not black and white.

The second paragraph of your post makes little sense. Can't have it both ways? Are you advocating ruining the career of good physicians in the hope of catching bad ones with a broad net? I am not advocating increased lawsuits, as the *vast majority* of them are groundless. That is not an opinion.

And yes, I am a doctor. You can check my long posting history for a bit of confirmation or at least support.

Re:Response to the "problems." (1)

tomhath (637240) | more than 4 years ago | (#30884466)

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!

Re:Response to the "problems." (1)

chooks (71012) | more than 4 years ago | (#30884692)

As sibling poster pointed out, the concept of "getting rid of bad doctors" is simplistic. For reference, see the Institute of Medicine Report To Err is Human [iom.edu] . One salient quote from the report brief [iom.edu] :

One of the report's main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group--this is not a "bad apple" problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.

In your example above with the wrong dosing, don't forget that there is a chain of people that that dose goes through -- e.g. the pharmacist, the nurse, etc...It is their jobs as well to question medication. In fact, nurses will state that if a wrong medication is given, then they are liable for it, even if the doctor ordered it (this is anecdotal, I do not know exact policies and procedures around this). Of course, people will argue that if nurses question a doctor they will never win. And while this argument is appealing to our preconceived notions of power structures and roles, the reality is different and there are procedures to escalate issues such as this. Again, this is to underscore that medical errors are mostly due multiple failures in the system or deficiencies in the system itself. Let's face it -- to expect perfection from one person (a doctor, a priest, the president, you name it) is unreasonable at best and irrational at worst.

Re:Response to the "problems." (0)

Anonymous Coward | more than 4 years ago | (#30884276)

So what was the inside story?

Re:Response to the "problems." (1)

Comatose51 (687974) | more than 4 years ago | (#30884664)

I can almost feel your frustration at being an expert in a crowd of Slashdot self-appointed experts. Thanks for the post and insights.

Re:most of the problems aren't technical (5, Insightful)

fuzzyfuzzyfungus (1223518) | more than 4 years ago | (#30883284)

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.

Re:most of the problems aren't technical (1)

systemeng (998953) | more than 4 years ago | (#30883938)

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.

Re:most of the problems aren't technical (3, Interesting)

anorlunda (311253) | more than 4 years ago | (#30884070)

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.

Re:most of the problems aren't technical (1)

drinkypoo (153816) | more than 4 years ago | (#30884278)

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:most of the problems aren't technical (2, Interesting)

iamhassi (659463) | more than 4 years ago | (#30884160)

"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 this shield is in place before treatments". You can put all the checklists and maintenance and safety toggles in place all day but when they ignore the checklist and safety toggles at some point you need to suck it up and start charging people with murder because firing them and sending them to another hospital to kill another patient doesn't really solve the problem does it?

However I'd agree the system could be improved: how about requiring a second operator to double-check the machine before the treatment is delivered? Ultimately it all comes down to money, is it cheaper to just keep killing people or implement a more reliable safety system? Until it becomes more expensive to kill people then it does to create safety systems they will continue to kill patients. This is why I support huge lawsuits against doctors and hospitals, because the faster we reach that killing/safety threshold the faster we'll reach a system that saves lives instead of taking them.

Re:most of the problems aren't technical (0)

Anonymous Coward | more than 4 years ago | (#30884732)

"Do you think saying "humans are flawed, deal with it" helps?"

Yes, actually. People aren't perfect. They never will be. So mistakes will happen. No amount of checklists, lawsuits, firings or prosecutions will change this.

So if there is a way to prevent an accident by making it harder to do it the wrong way than to do it the right way, then the machine should be designed that way (because if it can happen, it will). If a safety shield needs to be in place then the machine must not operate without it. Safety devices should be hard to override. On the other hand you should not have annoying safety devices that don't add real safety. Operator interfaces should be well thought out. Etc.

"This is why I support huge lawsuits against doctors and hospitals, because the faster we reach that killing/safety threshold the faster we'll reach a system that saves lives instead of taking them."

You are an idiot. Accidents are going to happen. There is nothing you can do to prevent them all. More lawsuits will mean more deaths due to less care or more deaths due to more unneeded care. In your quest to reduce deaths you will kill more people.

Re:most of the problems aren't technical (1)

fuzzyfuzzyfungus (1223518) | more than 4 years ago | (#30884734)

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 instant gruesome mangling, or death, people still fuck up. This is why properly designed equipment has, wherever possible, design features that make it hard to do serious damage with a small mistake.

You do want to emphasize, and take no shit about, your safety protocol. If checklists are empirically proven to reduce errors, and some hotshot is just too perfect for boring old checklists, he gets told that he can either shape up, or be too cool for checklists somewhere else, assuming he can get hired with the nasty recommendation you'd give him. Absolutely. If you have a well designed protocol in place, failure to adhere to it is negligence, even if nothing bad happens that time, and you don't want negligent people around(the flip side of this, of course, is that whoever designs the protocol and systems has a duty to make sure that they actually work. If your system of safeguards is so onerous that workers have to bypass it to get things done, they will, and then management will have to look the other way, since they also need things to get done, and the system will fail).

Re:most of the problems aren't technical (1)

mjwx (966435) | more than 4 years ago | (#30884202)

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. This means that we have to investigate what went wrong, this also means that some responsibility must also be taken but pointless finger pointing helps no-one and fails to fix the issue.

Mistakes happen, but the same mistake should not happen twice and it's normally the blame/blame aversion culture that causes this.

hollywood upstairs medical college (1)

Joe The Dragon (967727) | more than 4 years ago | (#30884608)

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

Re:Not a new problem (0, Funny)

Anonymous Coward | more than 4 years ago | (#30883104)

Its okay, once the Cylons take over and successfully wipe out humanity(this time around) then these errors will be a thing of the past :D

Re:Not a new problem (2, Informative)

RDW (41497) | more than 4 years ago | (#30883610)

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 original plan'), and that no appropriate error message is generated ('There is no warning message presented during the approval stage indicating that the Primary Reference Point is missing.'). This may well be completely unrelated to the NYT incidents, but it's interesting (though perhaps not surprising) that behaviour of this type can still occur in safety-critical applications.

Re:Not a new problem (1)

QuietLagoon (813062) | more than 4 years ago | (#30883730)

This appears in textbooks.

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

This is scary... (2, Insightful)

xQuarkDS9x (646166) | more than 4 years ago | (#30882818)

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!!!

under the assumption (1)

Oxford_Comma_Lover (1679530) | more than 4 years ago | (#30883016)

Never assume about your medical professionals, at least not when it comes to surgery or cancer. Get referrals from people in the field who know what they're talking about. If you can understand it, read the relevant literature yourself and ask intelligent questions about your cancer. Well-respected surgeons can be terrible in the OR and highly-published doctors can fail to read the patient's chart. Most doctors try to do a good job--and they deserve respect for that. But if the doctor's attention isn't squarely on your case when you're in front of him, if he's not thinking about you, your options and the medical facts, if he's not up on the relevant literature... keep your eyes out for warning signs. Trust him up to a point, but get a second opinion if anything seems out of whack--and maybe otherwise. The fact is, medicine is a demanding thing to do well, and despite how hard it is to get into medical school, somehow, there's still a lot of bad medicine out there.

Above all, be respectful. Not only is it usually deserved on one level or another, but it can make a difference in the quality of care you receive and the frankness of the answers you receive. Because medicine is a highly political field.

Note: This is my personal opinion, and I am not a doctor, so do what you'd like; but if it were me, I'd do something like this.

Therac-25 (4, Informative)

slimjim8094 (941042) | more than 4 years ago | (#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:Therac-25 (2, Insightful)

mysidia (191772) | more than 4 years ago | (#30882848)

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:Therac-25 (1)

jhoegl (638955) | more than 4 years ago | (#30883184)

Those that operate the machines are still local. However, there are over seas doctors looking at your X-Rays. I know this to be fact.

Re:Therac-25 (2, Insightful)

Cryacin (657549) | more than 4 years ago | (#30883946)

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.

Re:Therac-25 (1)

mr exploiter (1452969) | more than 4 years ago | (#30883678)

Actually it was more than 2. Wikipedia is not always right.

Re:Therac-25 (1)

slimjim8094 (941042) | more than 4 years ago | (#30883734)

Actually that was just my memory. I assume there's some discrepancy with the numbers - between "suspected to have killed" and "killed as a direct result of"

This has happened before (3, Insightful)

Protonk (599901) | more than 4 years ago | (#30882836)

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).

More harrowing stories... (1)

pongo000 (97357) | more than 4 years ago | (#30882842)

...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.

Cancer therapy is dangerous (4, Interesting)

MichaelSmith (789609) | more than 4 years ago | (#30882852)

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.

What is the denominator data? (3, Insightful)

dorpus (636554) | more than 4 years ago | (#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.

Re:What is the denominator data? (-1, Flamebait)

Anonymous Coward | more than 4 years ago | (#30883080)

Bayesian shmayesian. Humans have stepped on the Moon and are looking at pictures of Mars taken from Mars. If the odds of dying are 0.01% (I just made that number up), why don't we try to lower them even further? A risky procedure is "acceptable" (you used that word) only if it's not you who has to go through it. You are talking about mathematical probabilities here, but I want to live! Nothing more. Let's come up with a therapy that has 99.999999999% success rate, so we'd know that only a freak accident such as sudden reversal of the Earth's magnetic poles during the procedure could cause death. Sounds stupid? Sounds SF? We've been to the damn Moon, we've stepped on it and we have brought back evidence. Yet, we still fail to fix the issues we have "down here."

Probability is low? Sounds interesting! Hundreds of people died? No, thanks! No other thing I can try to cure me? Fuck you!

Re:What is the denominator data? (1)

Kell Bengal (711123) | more than 4 years ago | (#30883346)

If you have one week to live, but there's an operation that might give you another 10 years, or might kill you on the table, most people would take that chance. And that's what it is - taking a chance. Yes, I agree we should try to reduce the risks, but we have to be realistic and accept that things will go wrong.

Risk is a part of life - there is always a risk even for utterly trivial routine surgeries like having an ingrown toenail cut out. People have died as a result of that surgery, but very few. Probably more people die in cars on the way to the hospital. If we only did things that carried no risk no one would do anything.

You wax lyrical about going to the moon, but just remember three men died on the ground before we even got a moon rocket in the air. We've lost 14 astronauts in the STS program alone. Space flight is astonishingly risky and expensive. Stuff blows up All The Time. But we judged those risks to be worth the value of the enterprise.

So too with medicine.

Re:What is the denominator data? (1)

registrar (1220876) | more than 4 years ago | (#30883460)

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.

Re:What is the denominator data? (1)

Mr. Freeman (933986) | more than 4 years ago | (#30883572)

"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 someone's heart when they should have been removing the pancreas.

Regardless of how risky anything is, every attempt should be made to make it LESS risky. As safe as possible. No, it won't ever hit 100% success, but we should make every attempt to get it as close as possible.

Never share someone else's radiation (0)

Anonymous Coward | more than 4 years ago | (#30882938)

You may be tempted to share someone else's radiation to catch a buzz or light one up or ride the blue dragon as you kids say. But if you read the bottle, you will see: "Federal law prohibits the transfer of this radiation to any person other than the patient for whom it was prescribed." Let this article be a warning to those looking for a cheap high or quickie chemo: Radiation Kills!

perspective (1)

wizardforce (1005805) | more than 4 years ago | (#30882984)

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 (4, Insightful)

Jaime2 (824950) | more than 4 years ago | (#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.

THERAC 25 (0)

Anonymous Coward | more than 4 years ago | (#30882988)

Great job on the therac25 tag!

IMHO: one should never forget about the Therac 25 incident, as a reminder of the impact on society of technology.

Human Error (4, Insightful)

devnullkac (223246) | more than 4 years ago | (#30882990)

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.

Re:Human Error (1)

CaseCrash (1120869) | more than 4 years ago | (#30883202)

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.

+1 Agree, whether it's a medical technician or a programmer, somebody fucked up.

Also, every time I hear "Not to put too fine a point on it" my brain immediately starts playing Birdhouse in your soul [wikipedia.org] , so thanks for that.

Re:Human Error (1)

Mr. Freeman (933986) | more than 4 years ago | (#30883600)

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".

When I was young, it sounded all quite unlikely... (2, Funny)

jgreco (1542031) | more than 4 years ago | (#30882996)

"Dr. David Banner: physician; scientist. Searching for a way to tap into the hidden strengths that all humans have. Then an accidental overdose of gamma radiation alters his body chemistry. And now when David Banner grows angry or outraged, a startling metamorphosis occurs..." Apparently they misspelled "rigor morphosis." Bah.

Surprise! (1)

Renraku (518261) | more than 4 years ago | (#30883030)

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.

A few ways to be dangerous.

Each treatment with radiation therapy involves HUNDREDS of variables. You aren't just applying radiation to a perfectly spherical mass in the abdomen. You could be applying it to a starfish shaped glioblastoma multiforme tumor in the brain, knowing that if you miss some of it, it will just grow back and they'll die from it anyway. You could be applying it to a bone marrow tumor, but you want to save the remaining bone marrow. Each of these situations involves a radically different configuration of the machine. The difference between a treatment dose and a face melting dose is only a few notches on a knob.

A knob that might be overlooked by a radiologist who has worked for 16 hours straight because the other one is off having a baby.

Re:Surprise! (2, Funny)

jhoegl (638955) | more than 4 years ago | (#30883176)

Yes, I too blame pregnant women for overworked coworkers and thus excuse any mistake they make, including death.

Re:Surprise! (1)

Renraku (518261) | more than 4 years ago | (#30884236)

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 (3, Interesting)

MBCook (132727) | more than 4 years ago | (#30883120)

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.

Re:Test Every Time (1)

CmdrPorno (115048) | more than 4 years ago | (#30883248)

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.

Re:Test Every Time (0)

Anonymous Coward | more than 4 years ago | (#30883254)

How exactly do you think they caught the errors?

Re:Test Every Time (2)

phantomcircuit (938963) | more than 4 years ago | (#30883392)

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.

Re:Test Every Time (1)

Mr. Freeman (933986) | more than 4 years ago | (#30883632)

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.

Re:Test Every Time (0)

Anonymous Coward | more than 4 years ago | (#30883758)

There are dosimeters (TLD, mosfets, etc..) one can use to measure the surface dose. The problem is that these require time and money. More importantly, afaik, the hospital doesnt get reimbursed for these measurements except for special cases. The bigger problem here is that the continuous use of technology is making people dumber/less aware/overconfident. For instance, the reliance on record and verify systems (software that loads and records delivered treatment parameters) in radiation therapy most likely decreases the chances of an error, but when an error does occur the error takes longer to find (i.e. 3 treatments or 20 treatments instead of 1) because everyone tends to believe the R&V software.

As for the cost-benefit-risk analysis, the article is slightly misleading without telling the total number of patients treated in their sample. I think its a safe guess that these problems occurred for less than 1% of all patients.

Re:Test Every Time (1)

joe_frisch (1366229) | more than 4 years ago | (#30884650)

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 this situation seriously and I believe would never proceed with beam operations if the safety systems we not operating as expected.

I would think that medical equipment would operate under the same standards. Operators and doctors should be trained to stop work any time the system does not respond as expected. (This is very simple: if the machine is not behaving exactly as specified in the operating procedures, STOP and call an expert). The "expert" is then held responsible for the correct functioning of the machine. If it fails after he gives it the ok - the line of responsibility is very clear.

I understand that there are serious consequences to shutting down a treatment center, but we sometimes shut down a billion-dollar accelerator center when there are questions about safety equipment. We of course keep experts on call so that any issues can be resolved quickly.

Disclaimer - I work at SLAC and represent what I have observed to the best of my ability, but I am not an official spokesman for the lab and am not directly involved in safety oversight.

shocker (0)

Anonymous Coward | more than 4 years ago | (#30883242)

orly?

How much do you pay the techs? (0, Flamebait)

Gothmolly (148874) | more than 4 years ago | (#30883250)

So you take a wave motion gun, and give it to some techs who make $15 an hour, and are union, and you expect them to care where it's pointing?

Re:How much do you pay the techs? (0, Flamebait)

Jaime2 (824950) | more than 4 years ago | (#30883706)

No, we take a potentially lethal device, and give it to some techs who make $15 an hour, and are union. If they kill anybody, we find out about it years later through some data mining, write a report, and send them to jail. That is more effective than doubling their salary and hoping that they are now less distracted due to the reduced financial pressure in their lives. Higher pay is for people who are hard to replace, not for people who just happen to be in a gateway position.

The problem here. (4, Insightful)

DavidTC (10147) | more than 4 years ago | (#30883298)

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.

In Other News (1)

DynaSoar (714234) | more than 4 years ago | (#30883606)

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 world wide and enjoy http://en.wikipedia.org/wiki/List_of_accidents_and_incidents_involving_commercial_aircraft [wikipedia.org] Feel free to discount the Sept 11 2001 entry as a statistical outlier. Take a calculator.

What I'd like to see is some in depth journalism investigation (a subset of investigative journalism) to determine how many accident fatalities due to inaccurate reporting of weather/road/building/etc conditions, suicides due to news reports detrimental to the victim, suicides among employees, and covert/extended suicide by employees via such as alcoholism occurred due to the NYT. And when the count is in, maybe a comparison about how hard it is to run a newspaper vs. running a linear accelerator based medical radiation system. And before you go counting how many people each takes, consider how much of the operation of the latter is automated and how many people it would take to do it without the automation.

Some buggy rad software comes from cheap companies (4, Interesting)

DaneM (810927) | more than 4 years ago | (#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!

It happens from time to time. (4, Informative)

jimicus (737525) | more than 4 years ago | (#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.

Dont worry! Iradiation a day keeps the doctor away (1)

trickyrickb (910871) | more than 4 years ago | (#30884146)

or at least at a safe distance

As a cancer patient in 89 (1)

gelfling (6534) | more than 4 years ago | (#30884190)

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

Happened to me in '82. (2, Interesting)

Wyatt Earp (1029) | more than 4 years ago | (#30884218)

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

I had radiation therapy... (4, Funny)

rbanzai (596355) | more than 4 years ago | (#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.

Reminds me of... (0)

Anonymous Coward | more than 4 years ago | (#30884564)

I remember reading in some programming instructional material a story of the Therac-25 [wikipedia.org] . A lovely device, killed 2 patients due to software errors. Always know your logic-trees!

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