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.

Re:highly trained morons

[Jophish]

Alternate title: Radiation Therapy Success Saves Lives

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.

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

[fuzzyfuzzyfungus]

Blaming software isn't the answer(outside of specific software bugs); but blaming humans, while fun and morally satisfying, is also dubiously useful from the perspective of the system as a whole(this does not, of course, mean that you should feel any compunction about sacking egregious cases).

For instance: The radiation shield/guide setup. Yeah, the nurse should have installed it, and she fucked up. However, it is a basic fact of humans that all of them fuck up from time to time, some more than others, and more under some conditions than others. Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the system as a whole very much. Instead, such safety critical systems should be designed to take human error into account. Routine use of checklists, for instance, has been demonstrated to reduce human error. Or, for the more high tech approach, the Radiotherapy machine could have a few extra sensors(RFID and optointerrupters) and the shield and guide units could be RFID tagged. If the machine does not detect the presence of the correct guides in the correct locations, it alerts the operators and refuses to provide a beam.

Humans are flawed, often annoyingly so; but they are what we have to work with. Luckily, it is possible to systematically characterize the form of flawedness exhibited by humans(eg. limits of short and long term memory, probability of making an error on a procedure of given complexity as a function of experience, and so forth) and design systems that, as much as possible, are resistant to those errors. This requires a combination of organizational changes(eg. control of working hours, verification of nonimpairment for critical staff, enforced use of checklists and procedures, firing atypically unreliable staff) and technological changes(substitution of highly reliable barcodes/RFIDs for unreliable handwriting, automated sanity checking, marking patients before surgery, machines that refuse to operate unless their interlock conditions are met, etc.)

Some of this is just a matter of time, some of it will piss off doctors, and some of it will probably piss off patients; but building reliable systems is possible.

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!