Radiation Therapy Mistakes Cost Lives

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."

Comments

highly trained morons

[timmarhy]

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

[Muad'Dave]

mains wiring is twin and earth with the earth wire not shielded and thinner than the other two cores.

It depends somewhat on where you're doing the wiring. Most houses these days are wired with what we incorrectly and generically call Romex, which is technically Non-Metallic (NM) cable. It has two current-carrying conductors (one black, one white) and a bare ground (earth to you) conductor. This would be hard to mess up based on color.

Once you graduate to non-protected wall wiring (like in garages, commercial bulidings, etc) you start using single strand wiring in conduit (EMT, Electrical Metallic Tubing) or (ENT, Electrical Non-metallic Tubing - the blue 'smurf tube'). For this you use a green-insulated conductor for ground instead of a bare one. The typical white (neutral) and black (hot) wires are there, but can be joined by a second hot (red). This is typically seen with 3-way switches and the like, as well as 220V circuits where there are two hots.

Commercial wiring is yet another ball of wax.

Not a new problem

[JoshuaZ]

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 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

[RDW]

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

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

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

[nbauman]

even in the USA under Medicare, Medicaid, military and veteran health care,

Lul wut? Have you ever -used- or know people who have used those services? They are terrible. Its much worse than any insurance provider

I don't get this. Do you have any first-hand experience with those services? I moved from private insurance to Medicare when I turned 65, and the only difference was that my premium went from $525 to $90 a month, same doctors, same services.

I'm not in the Veterans' Health Services, but I know doctors who have joint appointments and perform surgery at the VA health center and at the top New York City academic medical centers. I've seen studies of different conditions, like BPH and cancer, where the VA hospitals had some of the best treatment outcomes in the country.

I'm sure you can find one person who was dissatisfied with Medicare, or the VA health care system, but when you look at the treatments overall, they do a great job.

(Medicaid is a special case with payment problems and access problems in some parts of the country, but that's the fault of legislators who don't want to pay to treat poor (black and hispanic) people.)

Therac-25

[slimjim8094]

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

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.

Response to the "problems."

[neapolitan]

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

Re:Response to the "problems."

[iamhassi]

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.

It happens from time to time.

[jimicus]

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.

Re:CHECKLISTS!

[qohen]

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

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 (If the topic interests you, btw, Amazon apparently is selling this $24.50 hardcover book for only $10).

Medicare

[Hebetsubeach]

My husband is on Medicare and the care he receives is outstanding. This last year he had several operations and hospitalizations. Much of his care has been at the University of Washington Medical Center, rated among the top 10 hospitals in the US, and he has had great care with extremely qualified doctors, professors with decades of experience. There are never any questions about his care not being covered. You hear horror stories of private insurance companies denying care or delaying decisions until the patient is too ill to recover. We've never had any problems with Medicare.

Re:Yeah, I know.

[Anonymous Coward]

Damage to the ureter and kidneys is a common complication in hysterectomies. You were almost certainly told of the possibility in the consent forms. It happens not because doctors are evil or incompetent, but because surgery is difficult.

It sounds to me they are doing exactly what they need to be doing in this case: they caught the problem early and they are trying to repair it.

Your cynicism and attitude are only making things worse. Work with the staff, be nice, and her chances of a good outcome will go up.

Re:Yeah, I know.

[pydev]

This fiasco sounds like it was at least somewhat avoidable with the application of a modest amount of discipline.

Do you have the slightest idea what a hysterectomy entails?

Damage to the ureter and kidneys is a common complication for hysterectomies. This clinic at least caught it in time and looks like they are on top of it.

It's attitudes like yours that cause health care costs to spiral out of control. I'm sorry, but medicine can't fix everything, and major surgery has a significant chance of killing you.