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?"

Comments

Not the engineers fault

[PhasmatisApparatus]

Requiring that doctors RTFM is the first step.

Re:Not the engineers fault

[RobertLTux]

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]

Re:Not the engineers fault

[uncqual]

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....

HULK MAD!

[BumbaCLot]

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

Anyone else read this as David Banner?

Re:Default setting...

[eln]

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.

Re:Will errors ever go away?

[argent]

The machine didn't build itself!

SPEAK FOR YOURSELF, MEATSACK!

Re:Will errors ever go away?

[Arthur Grumbine]

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.

Re:Will errors ever go away?

[FatdogHaiku]

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.

Re:Will errors ever go away?

[Itninja]

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.

Re:It's About Automation

[dgatwood]

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

Re:It's About Automation

[Tired and Emotional]

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