Mr. Jerome-Parks died...in 2007. He was 43.The accompanying graphics do a first rate job of laying out the situation and resulting mistakes.
A New York City hospital treating him for tongue cancer had failed to detect a computer error that directed a linear accelerator to blast his brain stem and neck with errant beams of radiation. Not once, but on three consecutive days.
I won't even try to summarize - it's worth a read.
2 comments:
I agreed with your sentiment when I read this. I have to say though that after reading "Complications", my guess is that if you really examine most any part of the medical profession, you will come out with the same feeling.
It does beg the question, why do these therapy devices default to lethal radiation? It's almost cartoonish.
Exactly. The idea that there is no failsafe when the system gets confused is just mindboggling.
When the system is going to emit lethal radiation - the system should shut down. There shouldn't be an option for an operator to screw that up.
Bad design that kills people.
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