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.

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

[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.

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: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.