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CT Scan "Reset Error" Gives 206 Patients Radiation Overdose

jeffb (2.718) writes "As the LA Times reports, 206 patients receiving CT scans at Cedar Sinai hospital received up to eight times the X-ray exposure doctors intended. (The FDA alert gives details about the doses involved.) A misunderstanding over an 'embedded default setting' appears to have led to the error, which occurred when the hospital 'began using a new protocol for a specialized type of scan used to diagnose strokes. Doctors believed it would provide them more useful data to analyze disruptions in the flow of blood to brain tissue.' Human-computer interaction classes from the late 1980s onward have pounded home the lesson of the Therac-25, the usability issues of which led to multiple deaths. Will we ever learn enough to make these errors truly uncommittable?"

18 of 383 comments (clear)

  1. Not the engineers fault by PhasmatisApparatus · · Score: 5, Funny

    Requiring that doctors RTFM is the first step.

    1. Re:Not the engineers fault by RobertLTux · · Score: 5, Funny

      I see you are about to fry this patient like an egg (doseage set for multiples of normal protocol)
      would you like me to

      1 reset the machine to standard defaults
      2 book you a flight to africa
      3 call your lawyer now
      4 forge the documents to show %person% did the treatment

      or
      You Are about to kill this patient [cancel] or [allow]

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    2. Re:Not the engineers fault by uncqual · · Score: 3, Funny

      Just make the button detect authorized fingerprints only and require a heartbeat in the finger and also scan the operator's retina and alter lighting to make sure that the iris responds "correctly" to random changes in light level.

      Bet you can't circumvent that with just duct tape. Now, with an Arduino, some peripheral hardware and a few spare evenings....

      --
      Why is there an "insightful" mod and why isn't it "-1"? If I wanted insight, I wouldn't be reading /.
    3. Re:Not the engineers fault by uncqual · · Score: 2, Funny

      Reminds me of "back in the days" of the early mass market terminals that allowed you to program keys to send sequences of arbitrary characters.

      One of the system admins at school was trying out the latest and greatest such beast in his office before deploying it and thought it was a good idea to program F1 to send his userid and password. He also thought that the terminal would not retain the memory when he unplugged it to deploy the device to the public terminal room.

      He learned that two stupid thoughts can be much worse than one stupid standalone thought.

      --
      Why is there an "insightful" mod and why isn't it "-1"? If I wanted insight, I wouldn't be reading /.
  2. HULK MAD! by BumbaCLot · · Score: 5, Funny

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

    Anyone else read this as David Banner?

  3. Re:Default setting... by eln · · Score: 4, Funny

    That's really not fair...you have no idea that people would die from that radiation. It's at least equally likely they would develop super powers, join up with others who have received similar doses of radiation, and form a crime fighting team of mutants.

    All I'm saying here is we shouldn't just dismiss this as a bad thing until we've fully explored the legislative and societal implications a team of crime-fighting mutants with superpowers would have.

  4. Meh... by Machupo · · Score: 2, Funny

    What's a few hundred rem among friends?

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  5. Re:Will errors ever go away? by argent · · Score: 4, Funny

    The machine didn't build itself!

    SPEAK FOR YOURSELF, MEATSACK!

  6. Oh great by Tony+Hoyle · · Score: 2, Funny

    Now there are 206 hulks running around.

    Just don't make them angry.

    1. Re:Oh great by SmlFreshwaterBuffalo · · Score: 2, Funny

      Think they're mad now? Just wait until they get the bill.

  7. Re:Will errors ever go away? by Arthur+Grumbine · · Score: 4, Funny

    The machine didn't build itself!

    SPEAK FOR YOURSELF, MEATSACK!

    Oh, yeah?! Well who built your first model, you bucket o' bolts! And don't give me that FSM nonsense. Everyone knows that the Fantastical Spawning Machine was truly the work of humans, inspired by the intelligently designed schematics given to us by the noodley appendage of the true FSM.

    --
    Now that I think about it, I'm pretty sure everything I just said is completely wrong.
  8. Re:Will errors ever go away? by FatdogHaiku · · Score: 4, Funny

    SPEAK FOR YOURSELF, MEATSACK!

    Scanning with high intensity radiation reveals he is in fact about 60 percent water, 16 percent protein, 15 percent fat, and about 3 percent nitrogen... So, more of a stringy, greasy, slightly gassy water bag really.

    Sorry about the high levels of radiation used to obtain the data, your armpits should stop smoking any minute now.

    --
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  9. Add a dialog box... by ArcadeNut · · Score: 2, Funny

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

    Are you sure you want to kill this patient?

    Yes No Retry

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  10. Re:Will errors ever go away? by Itninja · · Score: 4, Funny

    Don't be such a dolt. The machine is the product of evolution. Millions of years ago a bolt of lightning hit some random alloys and a simple logic circuit was born. Fast-forward to now, and *poof* CT scanner! It just make sense.

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  11. Must have heard wrong... by Kratisto · · Score: 2, Funny

    I always thought it was 10% luck, 20% skill, 50% concentrated power of will, 5% pleasure, 50% pain, 100% reason to remember the name.

    --
    Conscience is the inner voice which warns us that someone may be looking.
  12. Re:It's About Automation by dgatwood · · Score: 3, Funny

    Was that before or after your car hit the bottom of the ravine?

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  13. Re:It's About Automation by Tired+and+Emotional · · Score: 3, Funny

    I don't know. I never have really understood Statistical Mechanics and I have probably not already died in a car accident.

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    Squirrel!
  14. Re:It's About Automation by ResidntGeek · · Score: 2, Funny

    You're saying it's better NOT to find the bug in the code responsible for turning off the X-ray?

    Jesus, what must your code look like?

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    ResidntGeek