The Radiation Boom
January 30, 2010 4:58 PM   Subscribe

As Scott Jerome-Parks lay dying, he clung to this wish: that his fatal radiation overdose — which left him deaf, struggling to see, unable to swallow, burned, with his teeth falling out, with ulcers in his mouth and throat, nauseated, in severe pain and finally unable to breathe — be studied and talked about publicly so that others might not have to live his nightmare.
From the first of a series of articles by the New York Times, putting the spotlight on what happens when radiation therapy goes wrong.

One surgeon blogger points out that checklists, commonly used in surgeries (and advocated by Atul Gawande), might have prevented this. However, as detailed by the second article of the series, the rapid development in radiation treatment technology bears part of the blame as well:
In Louisiana, Landreaux A. Donaldson received 38 straight overdoses of radiation, each nearly twice the prescribed amount, while undergoing treatment for prostate cancer. He was treated with a machine so new that the hospital made a miscalculation even with training instructors still on site.
Faulty software mixing badly with radiation therapy is nothing new (previously).
posted by Bukvoed (49 comments total) 11 users marked this as a favorite
 
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Poor man. As if cancer wasn't enough.
posted by Decimask at 5:14 PM on January 30, 2010 [1 favorite]


.
posted by mccarty.tim at 5:18 PM on January 30, 2010


One surgeon blogger points out that checklists, commonly used in surgeries (and advocated by Atul Gawande), might have prevented this.
I kind of think computerized checklists - or even interactive decision tree software could greatly improve treatment. People have this idea of doctors all being House, able to figure things out through sheer smarts and gut instinct, but the fact is doctors actually screw up a lot And even if there are "Houses" out there what are the odds that your doc is one of them. Or that he's gotten enough sleep that day or otherwise is off his game?

Another benefit is that it would make data collection to analyze effectiveness incredibly easy.
He was treated with a machine so new that the hospital made a miscalculation even with training instructors still on site.
Sounds like they should have tested the machine's usability along with the machine itself. I'm kind of amazed that after Therac-25 they would still make devices that easy to fuck up with.
posted by delmoi at 5:29 PM on January 30, 2010 [1 favorite]


I'm wth delmol here. How the hell are they blaming a new machine? Its kinda like saying "I know we were supposed to give you a shot...but the needle was all new and sparkly...and we got confused". Asshole administrators. I hope they hurt.
posted by hal_c_on at 5:36 PM on January 30, 2010


I notice that the hospital that over-irradiated Mr. Jerome-Parks did not require that the radiation tech do a test run of the software prior to the session, but only suggested it, due to a "staffing shortage."

there should never be a staffing shortage in a medical setting in a developed nation. don't we pay enough goddam money?
posted by toodleydoodley at 5:40 PM on January 30, 2010 [22 favorites]


"Without a doubt, radiation saves countless lives, and serious accidents are rare." But what the hell, right? Sensationalism sells papers.
posted by 1-2punch at 5:40 PM on January 30, 2010 [3 favorites]


Wow, I remember reading about the Therac-25 incidents, but this part is astounding: "There was only one person programming the code for this system and he largely did all the testing."

That is just... christ.
posted by Civil_Disobedient at 5:46 PM on January 30, 2010 [2 favorites]


sure, sensationalism sells papers. OTOH, when you put your palm over the mouth of a bottle of coke and shake it up, the resulting explosion is impressive.

the price of the settlement for Mr. Jerome-Park's fatal injuries was a gag order, which is terribly inhumane. you basically told someone - hey, it's not only possible to take a person who has a good chance of recovering from cancer and kill him horribly, we can make it so you can't warn anyone about that.

medical settlements, caps, gag orders and fuckups are at the center of the health care debate for many people, because they think that as bad as things are, careless fatal accident-wise, they'll be ten times worse with the gummint and its sovreign immunity-ness in charge of everything.

stuff like this - half-assed procedures, catastrophe, then settlement plus gag order - is what gives malpractice reform a bad name.
posted by toodleydoodley at 5:53 PM on January 30, 2010 [3 favorites]


Poor bastard.
posted by Wataki at 5:55 PM on January 30, 2010


Medicine and technology have an exceedingly uneasy relationship, in my experience. Poorly QA-ed, antiquated software of incredibly poor design? Everywhere in medicine. While I have no particular familiarity with the software used to run interventional radiology equipment, I wouldn't expect it to be that much better than what I've seen elsewhere in this business, hooked up to a particle accelerator though it may be.
posted by killdevil at 5:58 PM on January 30, 2010 [2 favorites]


"Without a doubt, radiation saves countless lives, and serious accidents are rare." But what the hell, right? Sensationalism sells papers.
Hey, people drive around all the time and they don't die, why the hell do we have worry about silly things like sticky gas pedals?
the price of the settlement for Mr. Jerome-Park's fatal injuries was a gag order, which is terribly inhumane.
Of course, you can't enforce a gag order against someone who's dead.
posted by delmoi at 6:02 PM on January 30, 2010 [1 favorite]


Of course, you can't enforce a gag order against someone who's dead.

true, and he should give them a good haunting. but isn't his wife also enjoined?
posted by toodleydoodley at 6:10 PM on January 30, 2010


Christ. . .I just underwent 3 different scans. . .diagnostic, but still.
posted by Danf at 6:16 PM on January 30, 2010


This was physically painful for me to read. It's so awful and so preventable-- do the opponents of "sensationalism" think it would be better to sweep such incidents under the rug and *not* expose them? What if it were you who were the victim-- or someone you love-- and your case happened *after* a newspaper had decided, naw, not worth covering, let's avoid the sensational?

I think "gag order" settlements should be illegal in cases where there is a public interest in the truth. The malpractice attorneys I know who aren't ambulance chasers often strongly warn their clients against taking these deals-- they've worked with cases where kids have been killed by dangerous "treatments" and it's outrageous for parents who have lost their children to be denied the opportunity to use this unimaginable event to at least have some chance at preventing other parents from suffering similar losses.
posted by Maias at 6:36 PM on January 30, 2010 [14 favorites]


I feel like this is another story that the crazy anti-vaccination guy in my lab is going to point to as evidence that modern medicine is a scam. That being said, that guy's craziness does not mean that we should just ignore this story, which would be at least equally crazy.
posted by !Jim at 6:40 PM on January 30, 2010


The problem with checklists (especially computerized checklists) is that people get used to them and/or start to just check off steps, and then you're back to the same issue of neglect. As the article said, in almost all these cases there were safety displays which showed that the radiation limiters were wide open, but the operators weren't looking at them. Checklists will help, but only as part of a systemic change toward teamwork and mutual oversight. Given even a little cross-checking, somebody would have been able to catch all of these errors.

That said, I think the software/hardware designers are largely at fault here. It's basically a death ray; you can't just throw it together and toss it out the door! C'mon, radiation software which crashes? Not once, but several times in one session? Radiation software which fails to save settings? Radiation software which doesn't even blare an alarm at the user when the radiation limiter is open?! There should be multiple failsafes to prevent that. You shouldn't even be able to turn the goddamn thing on with the limiter open, not without tons of hoop-jumping, including at least one hardware failsafe. It should probably refuse to start in any setting until the doctor -- not the tech, not the nurse, not the janitor -- checks off on a test run which shows exactly what it's going to do.

With any luck, this is exactly where these machines will end up... but in the meantime, people will get killed unless the medical staff are right on the ball, every single time.
posted by vorfeed at 6:50 PM on January 30, 2010 [16 favorites]


Well, yes, it would be dreadful if people forsook potentially-lifesaving radiation treatment because of this article, but when lapses in oversight (at the individual, hospital, and state level, to say nothing of the equipment and software manufacturers) are causing horrific and sometimes fatal injuries like these (and when, in spite of extraordinary measures having been taken prevent individual liability, these are still being grossly under-reported), I don't see how one could argue against this kind of information being made available.

It's precisely this kind of journalism that has me terrified of what we may lose in the financial shakeup of the publishing industries.
posted by wreckingball at 6:57 PM on January 30, 2010


Wait, what? This is how many decades after Therac-25? WTF people?
posted by polyglot at 6:59 PM on January 30, 2010 [1 favorite]


You shouldn't even be able to turn the goddamn thing on with the limiter open, not without tons of hoop-jumping, including at least one hardware failsafe. It should probably refuse to start in any setting until the doctor -- not the tech, not the nurse, not the janitor -- checks off on a test run which shows exactly what it's going to do.

Each item on your list is an accessory that will cost X dollars, where X is an amount of money that could potentially be disbursed to shareholders.

One of the things I've discovered working in healthcare (in a technology-intensive field, no less) is that technological failsafes are only implemented -- virtually without exception -- because the Federal Government demands that they be implemented, rather than due to the (often non-existent) goodwill or competence of the medical provider.
posted by Avenger at 7:04 PM on January 30, 2010 [13 favorites]


Sometimes hubris overrules common sense. A couple years ago, Beth Israel Deaconess Medical Center in Boston had a highly publicized case in which a surgeon operated on the wrong side of a patient. To its credit, the hospital was very open about the mistake and remediation (which centered in part on the sort of checklists Gowande suggests), but even still, not everybody got on board with the program.
posted by adamg at 7:33 PM on January 30, 2010


Each item on your list is an accessory that will cost X dollars, where X is an amount of money that could potentially be disbursed to shareholders.

That's why I said "should". As in, we should be living in a society of responsibility and prosperity -- one in which companies can best serve their shareholders by creating a solid product and then supporting that product, not by cutting corners until they finally make Marie Curie's lifetime record look like AAA baseball.

Hey, you think we could fit a tumbril into one of these radiation rooms? I've got an idea...
posted by vorfeed at 7:37 PM on January 30, 2010 [1 favorite]


In many cases checklists are administered by nurses, who interview the doctors and are empowered to stop the treatment from taking place unless the checklist has been completed properly.
posted by mai at 7:37 PM on January 30, 2010


.
posted by limeonaire at 7:47 PM on January 30, 2010


As the article said, in almost all these cases there were safety displays which showed that the radiation limiters were wide open, but the operators weren't looking at them.

Right. And when the hit the button that would start treatment, the machine should have locked, with a big 120pt warning about how there were no limiters in the beam.

Having nurses -- who are used to doctors and don't take the god-like attitudes well -- run the checklists is another good thing.

But really, the key is you have to drill it into people that you must follow the procedures, you must have someone else *verify* that you have done so, and you must *publicly fire for cause* anybody who treats a patient in violation of those procedures.

And, of course, if the fucking machine crashes, you must NOT PUT A GODDAM PERSON INSIDE OF IT. PERIOD. You know the machine isn't stable, which means you can't trust the thing, and yet they still stuck someone into it, despite the fact that it crashed while they were setting up the treatment plan?

Yeah, the manufacture deserves to be hauled out and shot for delivering that sort of crap, but the doctor who put that man in the machine while it was going tits up should be put in the same goddamn machine and have the dials turned to 12.

That's unforgivable. Simply unforgivable. Everyone who touched that machine needs to be fired, if not prosecuted. "Hey, this knife just randomly extends at times, but we've just rebooted it, so I'm going to use it during your surgery!"
posted by eriko at 7:57 PM on January 30, 2010 [12 favorites]


You know what would stop this? Huge fines. Fine the hospital a million dollars every time one of these accidents happens. Don't make the patient try to sue. The government should just impose the fine. I bet we'd see checklists, failsafes, and all kinds of things to prevent acidents then. Almost kill a bunch of babies because you give them too much blood thinner? An automatic million bucks per kid per dose. It would become profitable to be careful.

I also think malpractice insurance is a load of crap. Doctors and other medical personnel need to be regularly tested on each procedure they perform and not permitted to touch any equipment they aren't approved on. Insurance would go down if the small number of doctors and facilities who are responsible for most of the screw-ups could be weeded out. It's terrible that the repeat offenders are so rarely punished. An osteo-surgeon in my area screwed up almost 20 people before the hospital fired her. I hear she's working in Wisconsin now, doing the same thing. This has got to stop.
posted by irisclara at 8:06 PM on January 30, 2010 [9 favorites]


Two sad things struck me as I read this.
1. They didn't see the mistake on the computer because they were paying attention to the patient to make sure he didn't vomit. Ironic and unfortunate.

2. Checklists can't solve human error, especially with the horrible state of health care these days. A couple years ago, we had a tragic local case in which a 16-year-old girl died while in labor because the nurse injected an epidural anesthetic (instead of penicillin for an infection) directly into her IV line. Now, there were at least two or three protocol violations in that case (didn't check a barcode, didn't scan the patient's wristband, etc.), but the nurse was coming off of a 16-hour shift (on a holiday) that had ended at midnight; she slept over at the hospital and went back on duty at 7 a.m. No wonder she made a mistake.

I worked for an electronic medical records company several years ago. We were always telling our customers things like "Isn't this great? Your preloaded order systems will reduce errors because there won't be any misread handwriting!" Yeah, but if you type in medication combo 0994 instead of 0995, that's a heck of a difference. And never mind the other computer errors, as the article states.

So I don't know whether to be thrilled at the promise of new medical advances or terrified by the many new ways they could mess me up.
posted by Madamina at 8:21 PM on January 30, 2010 [1 favorite]


I worked for an electronic medical records company several years ago

Epic FAIL.

(Sorry. Little EMR joke.)
posted by Herodios at 8:37 PM on January 30, 2010 [5 favorites]


This kind of thing is why I'm a big fan of no-fault compensation for injured patients. Right now the medical malpractice system combines compensation with punishment. As a result, the doctor has an enormous personal and financial stake in avoiding punishment and therefore an enormous personal stake in making sure the victim isn't compensated.

A better approach would be a no-fault compensation system for patients along the lines of worker's comp. Lose a limb? That's X thousand dollars. Lose an eye? Y thousand. Die? Z thousand. All the amounts would be standardized for quick, straightforward, few-questions-asked payouts indexed to inflation, cost of living, and income. The system would be paid for by health care practitioners and hospitals as a kind of insurance program. Their premiums would go up if a lot of their patients are injured, which would encourage them to fix things.

Then, entirely separate from the question of injury, is the question of whether the doctor's behavior should be punished. That would be the province of the state medical board and the hospital's own internal review system.

Of course, in cases of intentional wrongdoing or reckless behavior, the victim would still be able to sue the doctor directly and not be limited to the no-fault compensation. And of course no one would ever have to submit to a gag order in order to be compensated.

New Zealand has a no-fault compensation system along these lines through the Accident Compensation Corporation scheme, and it seems to work pretty well.
posted by jedicus at 9:58 PM on January 30, 2010 [9 favorites]


And you pay how much for your medical treatment?
posted by a non e mouse at 10:36 PM on January 30, 2010


Less than the United States, with better objective outcomes (like lifespan and infant mortality).

Like the rest of the developed world.
posted by rodgerd at 11:16 PM on January 30, 2010 [11 favorites]


Yes, I'd suspect a system like the above would be cheaper than malpractice insurance. Administration and legal fees cost roughly half as much as the actual malpractice claims paid -- centralizing and standardizing the system would probably significantly lower costs to doctors and hospitals, which should in turn lower costs for their patients.

Or, as that article puts it, For every dollar paid in malpractice insurance premiums, only about 40 cents goes to injured patients. The remainder is absorbed by insurers’ administrative expenses and litigation expenses. Compared to other compensation systems that rely on administrative rather than legal processes to direct compensation to injured people, such as Social Security Disability Insurance or worker’s compensation, these transaction costs are extremely high.

As always, it's often in the insurance company's best interest not to pay. This leads to billions wasted on legal wrangling, not to mention the continued suffering of patients who have to fight for compensation for their injuries. And only about 2% of injuries due to medical negligence even become claims, leaving everyone else out of luck. Honestly, it's sort of hard to imagine a compensation system worse than the medical malpractice industry, at least from the point-of-view of society...
posted by vorfeed at 11:55 PM on January 30, 2010


Despite having some lovely tattoos on her chest, my mom received radiation on the wrong side of her (left lung instead of right lung) a few years back. It was never clear what the heck happened, and given that it wasn't dispositive of the eventual outcome of her cancer we never really pursued it. But I have often wondered how frequently stuff like that occurs.

This article was heartbreaking.
posted by miss tea at 4:32 AM on January 31, 2010


And you pay how much for your medical treatment?

Here's a page on NZ's (out of pocket) healthcare costs:

Some examples:
Care in pregnancy and childbirth is free for New Zealand citizens and permanent residents
...
If your GP refers you to a specialist or hospital you can choose to go publicly or privately. Almost all essential medical services are provided free through the public health system (excluding dentistry and optometry).
...
Treatment for accident-related injuries is subsidised by the Accident Compensation Corporation (ACC), as long as this care is provided by a registered health professional. There may be a user part-charge for visits to GPs, or for physiotherapy, chiropractic and other recommended treatments.
...
Mostly, laboratory tests and x-rays are free.
...
Adult New Zealanders will usually pay $3 per item for subsidised medicines from a community pharmacy, though this may cost up to $15 if the prescription is from a specialist. Prescription medicine for children under six years is often free.
According to that page, though some things may cost money, and in most case there is an option for private care

There's also the issue of overall costs as well. according to this PDF NZ's overall heath-care spending in 2003 was $2,231 (7.7% GDP) per person compared to the U.S's $5,635 (15% GDP). Out of pocket per capita expenses were "n/a" and the US's were $793. There's been some growth of course. The latest data I could was from this WHO interactive statistical browser. In '06 NZ paid $2447, and the US paid $6714 per capita. in 2007 the U.S. spent $7439 per capita, or 16% GDP on heath care (I'm pretty sure they're measuring costs differently, though. I don't think there was a 6714-7439 jump in one year)

So the answer to the question is "not much as an individual" and "slightly more then 1/3rd as much as the U.S (36% in '06) overall"
posted by delmoi at 4:47 AM on January 31, 2010


irisclara You know what would stop this? Huge fines. Fine the hospital a million dollars every time one of these accidents happens. Don't make the patient try to sue. The government should just impose the fine. I bet we'd see checklists, failsafes, and all kinds of things to prevent acidents then. Almost kill a bunch of babies because you give them too much blood thinner? An automatic million bucks per kid per dose. It would become profitable to be careful.

I really hope this is a sarcastic joke. What the hell do you think taking a "million dollars"--an amount obviously chosen because "million" is a number that sounds awesome--from a hospital budget will do to the rest of the patients' care?

No-fault compensation is the only rational course of action. Prosecute malice. Investigate negligence and prevent it recurring. Forgive honest mistakes. In no case deprive the rest of the hospital's patients of care, and don't give out "lottery wins" greatly exceeding cost of care to plaintiffs and especially their and the hospital's lawyers.
posted by aeschenkarnos at 4:53 AM on January 31, 2010


In only the third comment in this thread, delmoi mentioned the Therac-25 accidents. That was the first thing I thought of as well, and it's always the first thing I think of when I see a story about radiation overdose accidents.

But I wonder how many people who operate these machines are familiar with those accidents, and others since? I wonder how many people who design these machines, or write the software from them, have studied the accident history of previous machines?

Maybe an accident history review should be required reading as part of the training to operate a machine like this. Or maybe it already is, in which case that's even more depressing.
posted by FishBike at 6:22 AM on January 31, 2010


As far as real consequences to the hospital, this incident could be classified as a sentinel event. If the hospital is accredited by JCAHO (wikipedia), there are some procedures that the hospital is expected to follow, and the results could, in theory, affect the hospital's JCAHO accreditation, and therefore their eligibility to receive Medicaid payments.
posted by dilettante at 7:48 AM on January 31, 2010


I'm in agreement with aeschenkarnos and jedicus here on no-fault compensation. It's easy to look at the clinician associated the medical error and want to throw the book at them (and there are posts like that above in this thread), but that's a short sighted course of action.

The case of pharmacist Eric Cropp is a good example of this. This is a case where an incorrect concentration of a drug unfortunately killed a pediatric patient. He ended up with a fine, some jail time, and the loss of his licensure. Something interesting - noted here and in my first link - the family of the deceased is pushing for new legislation that calls for the training of pharmacy techs to make sure that this type of error doesn't happen again. I don't think anyone would believe that Eric willfully committed murder. It seems like people are in general agreement that it was a mistake brought about by bad process.

So what is gained by throwing the pharmacist in jail and taking away his license? Expecting zero mistakes from a health care professional is all well and good until you realize that it's an unattainable standard. Cases like his should require exhaustive investigation to find the root cause of the problem and root it out, and in all of these cases the manufacturers of medical equipment, materials, and software necessarily need to be examined as well. It sounds like the software for this linear accelerator was woefully inadequate. Anyone who's spent any time in an inpatient pharmacy will notice safety hazards related to identical vials containing radically different drugs or microscopic writing that makes it nigh impossible to distinguish a 5% concentration from a 0.5% concentration. The health care industry is one where product usability is paramount, and it's sadly one where it's greatly lacking.

Even with this, though, I think we ultimately need to dial back the attitude where we want to find out who's to blame and punish them harshly. If we shut down every software vendor who has had a mistake in their code, I can guarantee that there would be no software in health care and that electronic medical records would not exist (which is a shame as software in general has done wonders for health care in terms of error checking and information accessibility). I understand where the anger comes from - when mistakes do happen they can be catastrophic. And professionals and vendors who are repeat offenders or clearly negligent should be run out of town. However, in health care it's all too easy for a competent, caring professional to make a mistake that can harm a patient. To some extent, that just naturally comes with the territory. All of the actions set in motion after an accident like this should be focused on one thing: finding out how to keep this from ever happening again.
posted by Consonants Without Vowels at 8:05 AM on January 31, 2010 [4 favorites]


So what is gained by throwing the pharmacist in jail and taking away his license?

So there should be no serious personal consequences when life-ending mistakes are made by health care professionals? Is that really what you're arguing for? I mean, we can all agree mistake-free health care is "unattainable," but does that have to mean there are no consequences for those who do make serious errors?
posted by mediareport at 9:33 AM on January 31, 2010 [1 favorite]


But I wonder how many people who operate these machines are familiar with those accidents, and others since? I wonder how many people who design these machines, or write the software from them, have studied the accident history of previous machines?

I had to take a course on ethics before graduating with a Computer Science degree. We spent a day or two on Therac-25. Obviously, not all schools are the same, but ours was pretty serious about making sure everybody knew what might happen if they screwed up.
posted by vorfeed at 10:17 AM on January 31, 2010


mediareport: So there should be no serious personal consequences when life-ending mistakes are made by health care professionals? Is that really what you're arguing for? I mean, we can all agree mistake-free health care is "unattainable," but does that have to mean there are no consequences for those who do make serious errors?

Nope, that's not what I mean (though I can definitely see how you got that from my post). There should be consequences, but I wouldn't want to frame this in the mindset of punishment. A fine may be appropriate as would be a probation, unpaid leave, and mandatory education. I also think people who commit mistakes should be compelled to report on why the mistake happened and be instrumental in championing and putting in place measures to mitigate such mistakes in the future.

I do not agree with the jail time and definitely not the suspension of his license. They've basically made it so that this pharmacist (who is, from the accounts I've read, a skilled and conscientious practitioner) can no longer practice period. This can be detrimental to the entire organization as not only do they have to replace the clinician (which may not be easy to do - did I mention there's a general nursing shortage in the US?), but they are also getting rid of probably the best source of information on why the accident happened in the first place. Also, what's jail going to do in this situation? If he did not willfully cause harm, what kind of rehabilitation are we expecting? The clinician knows that they harmed a patient - I don't think that's something they're readily going to forget.

We all need to realize that health care is still not 100% in terms of safety right now. We need to view mistakes with an eye towards prevention and towards moving to that 100% safety state, and not just punishment.
posted by Consonants Without Vowels at 11:24 AM on January 31, 2010 [3 favorites]


Early on in my career I was given an opportunity to do software testing of medical devices. The pay in medical software/hardware development was very good. I decided on a somewhat less lucrative path - I didn't want mistakes I made to cost lives.
posted by el io at 11:59 AM on January 31, 2010


I really hope this is a sarcastic joke. What the hell do you think taking a "million dollars"--an amount obviously chosen because "million" is a number that sounds awesome--from a hospital budget will do to the rest of the patients' care?

Nope, no joke here. Perhaps I should have said "a whole giant shitload of money" but not because it's awesomer. I, like many Americans am tired of being the victim of systems that maximize profits and externalize costs. Doctors and hospitals have NO RIGHT to earn money from providing poor care. They have no right to hold our care hostage. They have no right to kill or maim and tell us that if we stop them our care will get worse. Our care is worse.
posted by irisclara at 12:22 PM on January 31, 2010


One of the things I've discovered working in healthcare is that technological failsafes are only implemented because the Federal Government demands that they be implemented, rather than due to the goodwill or competence of the medical provider.

Wait, what about the invisible hand of the market!?
posted by Evilspork at 12:35 PM on January 31, 2010


FishBike: "But I wonder how many people who operate these machines are familiar with those accidents, and others since?"

A few years ago, a coworker of mine was studying to become a radiation tech. We don't teach this stuff but he was working here as a computer lab monitor because it paid better than a similar position where he studies.

So anyways, when I find out he's studying this I mention Therac and he's never heard of it. He goes on a research rampage and points out to me the next day that the company behind that fuck up is still in business, designing and selling nuclear imaging.
posted by pwnguin at 1:18 PM on January 31, 2010


So anyways, when I find out he's studying this I mention Therac and he's never heard of it. He goes on a research rampage and points out to me the next day that the company behind that fuck up is still in business, designing and selling nuclear imaging.

True, but AECL is a crown corporation, so it would probably take the federal government saying "we're shutting you down" to make it go away. Mere market forces or giant lawsuits alone probably wouldn't be enough.
posted by FishBike at 3:21 PM on January 31, 2010


Always wait for version .1
posted by Twang at 4:48 PM on January 31, 2010


When my dad had an angioplasty, he said the display system for the endoscopic camera crashed several times and had to be rebooted during the surgery. The surgeon said this was normal.

This blasé attitude toward computer failures, even in life and death situations, can be traced back to desktop PC software. We've come to expect such failures, and we work around them without hesitation. Now that so many tools are computerized, we treat everything with a screen and keypad the same way. Medical imaging system crashed? No problem, just power cycle it. Don't even bother reporting the problem, it always does that.

We don't tolerate this kind of unreliability from tools that don't look like computers. If your home furnace randomly changed temperature settings, you wouldn't ignore it, you'd call a repairman. If your car shut itself off on the freeway every time you drove it, you'd take it to the dealer and demand it be fixed. You wouldn't just shrug your shoulders and accept it.
posted by ryanrs at 5:29 PM on January 31, 2010 [2 favorites]


ryanrs: We don't tolerate this kind of unreliability from tools that don't look like computers. If your home furnace randomly changed temperature settings, you wouldn't ignore it, you'd call a repairman. If your car shut itself off on the freeway every time you drove it, you'd take it to the dealer and demand it be fixed. You wouldn't just shrug your shoulders and accept it.

Computers exceed mechanical machines in terms of complexity by a staggering amount. For example, I bet the furnace repairman completely understands the operating principles of the furnace and could recreate one himself given the proper tools. No computer technician completely understands windows. Hell, I'll bet the lead developers of windows wouldn't even say they completely understood all parts of it, or even that they understood all parts of it fairly well. And that's just windows - you have to take into account all of the myriad hardware and software that exists.
posted by Mitrovarr at 2:28 AM on February 1, 2010


Mitro,

Be that as it may, it is astonishing to see that there just *aren't* hardware failsafes that detect the software driver has crashed, and shift the machine into a zero radiation mode.

I mean, such things *can* be done. We know how to do them. Argh.
posted by effugas at 6:18 AM on February 1, 2010


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