TECHNOLOGY FOR CHANGE

Smarter Technology Tragedies, Part One

Joe Maglitta | Date: 01-28-10 | Comments

System failures in advanced radiation therapy machines and secretive trading programs highlight technology�s -- and users� -- destructive potential.

Most IT people are proud of helping to make the world a better place. And they should be. New technology continues to enable a profound parade of new conveniences (online shopping and charitable giving), productivity (Web collaboration, mobile apps), and better management of water, food, electricity, travel and other necessities. After more than two decades observing the industry, I remain awed by the ingenuity, intelligence and accomplishment of technologists. Each day I am genuinely eager to see how new technology will be cleverly applied to some pressing problem, big or small.

Yet two recent tragedies, one preventable, one predictable, reminded me this week that increasingly powerful technology requires increasingly greater caution, by creators and end-users alike.

Tragedy 1 - Fatal Radiation Therapy Overdose

Sunday�s New York Times featured a long investigative article examining the dangers of new radiation therapy machines -- specifically, �Linear Accelerators� that generate high-energy beams for Intensity Modulated Radiation Therapy, or IMRT.

�New technology allows doctors to more accurately attack tumors and reduce certain mistakes, its complexity has created new avenues for error -- through software flaws, faulty programming, poor safety procedures, or inadequate staffing and training. When those errors occur, they can be crippling.�

And horrifying. Consider the story of Scott Jerome-Parks, a former computer and systems analyst at CIBC World Markets. A non-smoker and light drinker, he unexpectedly developed tongue cancer, which his family and doctor believe was linked to his exposure at Ground Zero after Sept. 11, 2001. According to the Times, the New York hospital where Jerome-Parks was treated �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.�

The �fatal radiation overdose � 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 breath.�

He died in 2007, age 43.

Government investigators blamed St. Vincent�s Hospital for failing to catch the error and Varian Medical Systems, a leading supplier of radiation equipment, for flawed software running the radiation machine.

Similarly ghastly is the case of Alexandra Jn-Charles, a 32-year-old breast cancer patient treated at the State University of New York Downstate Medical Center in Brooklyn.

�[She] absorbed the first of 27 days of radiation overdoses, each three times the prescribed amount. A linear accelerator with a missing filter would burn a hole in her chest, leaving a gaping wound so painful that this mother of two young children considered suicide.�

Here too, subsequent investigation found crashing and other problems with a Varian machine (though a different model). Despite state warnings weeks earlier, on 27 occasions hospital staff failed to notice that a therapist had mistakenly programmed the computer, the Times reported. Jn-Charles also died.

An analysis of similar episodes in New York revealed a similar pattern of system and human error:
Radiation Mistakes (January 2001-January 2009)

(621 radiation mistakes attributed to 1,264 causes. Some top causes:
- Quality assurance flawed - 355
- Data entry calculation errors by personnel - 252
- Hardware malfunction - 60
- Computer software or digital information transfer malfunction - 24
- Override of computer data by personnel - 19
Source: New York Times analysis of New York State records
As the paper notes, the problem is hardly confined to New York:

A Philadelphia hospital gave the wrong radiation dose to more than 90 patients with prostate cancer -- and then kept quiet about it.

A Florida hospital disclosed that 77 brain-cancer patients had received 50 percent more radiation than prescribed because one of the most powerful -- and supposedly precise -- linear accelerators had been programmed incorrectly for nearly a year.

�We were just stunned that a company could make technology that could administer that amount of radiation -- that extreme amount of radiation -- without some fail-safe mechanism,� said a nurse and family friend of Scott Jerome Parks. Varian subsequently issued a warning and global software update which it said included a fail-safe.

Read Part Two in this two-part series here.