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

Cancer therapy is dangerous

[MichaelSmith]

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.

Re:highly trained morons

[Zerth]

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.

most of the problems aren't technical

[SuperBanana]

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?

Re:most of the problems aren't technical

[anorlunda]

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.

Test Every Time

[MBCook]

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.

Yeah, I know.

[gbutler69]

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:Not a new problem

[omglolbah]

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

Some buggy rad software comes from cheap companies

[DaneM]

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!

Checklists, etc.

[neapolitan]

Probably a lot of books written on it -- Atul Gawande did a pretty big "study" with safety checklist prior to OR activation. We have several checklists (independent of anesthesia) before starting any invasive procedure, so this is kind of behind the times. It is more targeted at foreign hospitals or places that have a lot of mid-level providers that are not used to things. If you are interested, the full study can be found here:

http://content.nejm.org/cgi/content/full/NEJMsa0810119

gbutler69 writes:
>Says who? Citation Please?
[snip a bunch of rhetorical questions]

From your questions I infer you are completely out of touch with this field in any sort of form. If you want a citation, do a tad of research on your own and you will discover things; I won't spoon-feed.

Poke around here to start (but some of this might be biased the *other* way.) Do a good deal of academic reading and you will get a good feel of what is going on:

http://www.sickoflawsuits.org/

Re:highly trained morons

[Hadlock]

Yep, my dad got radiation treatment, he got "gamma knife" treatment for brain cancer. You get a special plastic mesh helmet that is specifically molded to your head (for brain cancer paitents, it's molded to other parts for pancreas or breast cancer, etc paitents), and then there are marker dots on the mesh helmet that align with set lasers in the walls. so your body is properly aligned. Then the actual "gamma knife" is placed in the correct position so it creates a red + sign on the targeted area, which matches up with the plastic mesh helmet. Your name is also written on the helmet, and you fetch your own helmet from the same cubbie each time and put it on your own head. A tech makes sure it's secured and double checks that it's your helmet. Not only are you picking out your helmet, but they cross reference your name, and unless you have a very small head, only your helmet is going to properly fit you. The red + sign isn't going to lay "flat" and the laser dots won't line up. It's at least a triple redundancy mode of failure and it seemed to work pretty well. Added bonus: the table looks like that room in the bond movie where bond goes "you expect me to talk?" and the villan responds "no mr bond, i expect you to die! (maniacal laughter). It's kind of neat to do medicine in a room that looks like a bond villian's secret layer.