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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.
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.
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
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.
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.
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.
my karma will be here long after I'm gone
... 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.