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.

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?

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!