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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."
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.
If you mod me down, I will become more powerful than you can imagine....
People make mistakes with technology which results in unintended consequences. Giving someone treatment for the wrong disease may have adverse side effects.
Basically this only proves that people are stupid in general. I don't see anything wrong with this technology.
Sewage Treatment Facilities - "Our duty is clear."
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.
This is scary indeed when you are under the assumption that you are going into a hospital or clinic for a treatment like this, and assuming he/she is well trained and know what they are doing to your body... to read something like this makes one wonder just what, if any training they get to operate these machines?
How did one guy above me put it... Highly trained morons? I have to agree!!!
You must master your joystick like a fisherman masters bait! - Gimpy
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.
I have developed a truly marvelous proof of this comment, which this signature is too narrow to contain.
Therac-25 is only the most prominent medical radiation incident from the past 20 years or so. The IEEE linked at the bottom explores problems with replacing hardware interlocks (mostly literal interlocks) with software interlocks, which fell prey to memory errors, bugs and human intervention. Tools like this require constant diligence and skepticism, which is nearly impossible to maintain when faced with incentives to update, promote and distribute new technology. I suspect this will devolve into some meta-discussion about regulation, but look closely at the allegations regarding cover-ups in the Therac-25 case and this article--market response presupposes that customers and investors are informed about errors in products. Where companies downplay or obfuscate errors of this magnitude, public choice fails. Regulatory bodies won't work perfectly, but I suspect that their intervention in the market would reduce these errors at some high but acceptable cost (in either monetary terms or terms of new technologies forgone due to the cost of compliance).
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.
http://michaelsmith.id.au
These numbers don't mean anything unless we know how many procedures are conducted in total. It could be that the probability of a fatal complication, defined as (# of fatal complications) / (# of procedures) is quite low.
I took a course on clinical decision analysis last semester. Every intervention, even diagnostic ones, carry a risk. The risk needs to be weighed versus its benefit to determine its overall efficacy. If the patient is very ill and has a short life expectancy or very low quality of life, then even dangerous procedures become acceptable.
One can conduct analyses based on expected life expectancy, QALYs (Quality-Adjusted Life Years), QOL (Quality of Life), or from a purely economic point of view. How much is a patient's life worth? Is a 5-year-old's life worth more than an 85-year-old's life? What about a 45-year-old? This can get quite philosophical. One could even conduct an analysis against a combination of outcomes, though how we choose to weigh the different outcomes is arbitrary.
Bayesian probabilities figure heavily into these analyses, and they can give quite counter-intuitive results. For example, if a test for AIDS is 99% "accurate" (in terms of sensitivity and specificity), it can still have a very high false positive rate (if AIDS is rare in the general population). In this sense, the AIDS test carries a toll of emotional devastation for the false positives. It can be a challenge to convince the general public, even your average physician, of the validity of a model. A good model will have conducted sensitivity analyses to allow for the possibility that a given procedure may have a higher (or lower) risk than expected.
Not to put too fine a point on it, but buggy software is also human error.
What do you mean they cut the power? How can they cut the power, man? They're animals!
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?
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?
Please help metamoderate.
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.
Comment forecast: Bits of genius surrounded by a sea of mediocrity.
Yes, I too blame pregnant women for overworked coworkers and thus excuse any mistake they make, including death.
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
Slashdotter, ID #101. UIDs are in binary, right?
While, as nerds, everyone here leaps to 'computer error'(And everyone mentions that Therac-25 disaster we all learned about in comp sci 101.), computers aren't really responsible for a brain cancer patient getting treatment for breast cancer.
A computer might say where to aim the machine, but someone who was even slightly familiar with the case would say 'Um...the breasts? No, that can't be right.'.
What is responsible is the constant reduction in the amount of staff at medical facilities, and consequently, the inability for any actual checking or familiarity with patients.
Read the horrific description of what happened to Jerome-Parks, please notice that it was people trying program crashing machines, machines that were obviously screwed up, and no one bothering to actually look at the result. And then doing it twice more because no one bothered to look into the obvious mistake.
Essentially, the problem here isn't the Therac-25 one, where a shitty user interface resulted in the screen saying one thing and doing another. Note that in every described situation, the machine clearly described what it was doing. It wasn't 'doing something else besides what it said', it was doing what it had, incorrectly, been told to do. It said it was doing it, it did it. The machine worked perfectly.
It is equivalent of being a newspaper reporter, and Word crashes while I save my article...but I submit it anyway, and the front page of the newspaper is filled with gibberish. You know whose fault that is? Sure as hell not Word. It's my fault, it's the editor's fault, it's the guy doing the final check before the print run. If I were to claim the solution to this constantly happening was 'crash-proof software', I'd get laughed out of society.
Oh, but newspapers actually, you know, pay people to check that before spending thousands of dollars doing a print run. If only someone's life was worth more than that.
Yes, we can argue the machine should have fail safes to stop them from working in obvious stupid situations, but this just stops obviously stupid situations, and only overdoses. What is that is a perfectly reasonable dose...aimed at entirely the wrong spot, for someone with an entire different type of cancer?What if it's 100x what you should be getting, but still within the bounds of reasonable for certain extreme types of cancer? What if that is, in fact, practically no dose at all, so you die of a fucking treatable cancer because you got not treatment?
More to the point, why are we worried about this, when drug errors kill ten thousand times as many people? (Because machines often do have failsafes, unlike prescriptions.)
If only we had a system where all the money wasn't sucked out of the system by insurance companies, one where we actually paid to have competent medical staff who could actually watch what was going on, instead of spending ten damn seconds a patient.
If corporations are people, aren't stockholders guilty of slavery?
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!
Over-the-top Response Guy! Giving "Over-the-Top Responses" since 1970.
Heck, Therac-25 is the freakin' case study that people use to learn about the possible consequences of bad software design. You'd think somebody at the FDA would have heard of it and made some sort of link to the work they were doing before approving the successor to the Therac-25.
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!
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:
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.
People survive just fine with one arm? People survive just fine that are blind? People survive just fine who can't hear? People survive just fine with a permanent colostomy bag? People survive just fine with their tongue cut out? People survive just fine with one leg? People survive just fine with their face melted off with acid or burned off in fire? People survive just fine with their testicles mistakenly removed? People survive just fine with their dick cut off? People survive just fine without a bladder of any sorts?
You're welcome to accept any of these conditions any time you want jack-ass!
Over-the-top Response Guy! Giving "Over-the-Top Responses" since 1970.
Again, ridiculously simplistic analysis.
>you should be excited every time you hear a doctor is being sued for malpractice.
You have got to be kidding; that statement is simply ludicrous. I don't engage in some sort of weird schadenfreude when somebody gets sued, even if it were somewhat legitimate. Medical school is relatively difficult to enter, selects for the most driven people, and is a long process where several dozen people work with you and gauge your progress and abilities. *OF COURSE* bad doctors need to be stopped, just like "bad pilots" or "bad computer programmers." Indeed, a lawsuit is one of many ways, in fact a poorly targeted way, of doing this. There are many other options including board registration, hospital credentialing, and outcomes monitoring. Life is not black and white.
The second paragraph of your post makes little sense. Can't have it both ways? Are you advocating ruining the career of good physicians in the hope of catching bad ones with a broad net? I am not advocating increased lawsuits, as the *vast majority* of them are groundless. That is not an opinion.
And yes, I am a doctor. You can check my long posting history for a bit of confirmation or at least support.
Slashdotter, ID #101. UIDs are in binary, right?
Had radiation go wide during a 6 day cycle, radiation burns and good times. It was picked up the following cycle and "adjusted" for.
... and stuff like this makes me anxious. I had 30+ zaps to my leg. Initially there was a rather involved simulation to precisely aim the beam. They made a mold to hold my leg in place for the treatments and tattooed targeting dots on my leg.
They screwed up. It was completely bungled and part of the beam was aimed to go right down the side of my leg, frying the top layer of skin. Within a couple of treatments they adjusted it and just used sharpies to make new targeting dots.
One day I was lying on the table with my balls in the lead sphere to protect them when over the PA I heard the old Windows error sound. Scared the crap out of me until they told me they only used Windows for their scheduling software.
CHECKLISTS! Pilots have an easy job and they need them. huge benefits resulted from giving them checklists.
Doctors and medical workers must be forced to use checklists. period.
Democracy Now! - uncensored, anti-establishment news
- 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.
And yet, despite all those checks, surgeons still fuck it up. And of course, why were all those checks necessary in the first place? Answer: incompetent, arrogant surgeons/doctors. You make it out like it's a rarity. http://www.google.com/webhp?hl=en#hl=en&q=surgery+"wrong+side+of+the"
*Golf clap*. You just justified something completely moronic (operating on the wrong part of the patient) by saying that because it's done so many times, we should excuse the "few" idiots.
I don't care how many fucking operations you do. The surgeon should be aware of the patient's history to the extent that something as unbelievably simple as "which side am I operating on" should not be possible. How can they possibly treat/operate effectively if they can't even get something that simple done?
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.
It IS SO SIMPLE. Fire and criminally prosecute doctors, nurses, and surgeons who injure or kill patients through their incompetence. Watch as the medical profession suddenly becomes more interested in competence, safety, etc- and not just exploiting med students. If patient safety is so important, why are med students run through a meat grinder? What a bunch of macho bullshit to claim it's to "test" them. When I'm seen by a med student who is operating on 3 hours of sleep over the last 48 hours, I'm not going to get anything remotely approaching a level of decent care.
By the way, take that ad hominem and cram it up your ass; I never applied for med school. Zero interest.
Please help metamoderate.
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/
Slashdotter, ID #101. UIDs are in binary, right?
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.