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In November of the year 2000, a software malfunction lead to the deaths of 8 patients of a Panama City cancer clinic, while at least 20 other patients have developed symptoms linked to over exposure to radiation. The software malfunction lead to these patients being over exposed to gamma radiation as part of their radio therapy while being treated for cancer. The software was supposed to allow the doctors to calculate the appropriate dosage of radiation for the patient for a given session of the therapy. It did this by letting the doctor draw onto the screen of the computer the placement of the metal shields (called blocks), which are used to protect the healthy tissue from the harmful radiation. The software would then calculate the appropriate dosage of radiation. The problem arose from the fact that the doctors wanted to place five separate blocks while the software only allowed for the placement of four individual blocks. The doctors discovered that they could get around this restriction by drawing a single large block with a hole in the middle instead of five individual blocks.
What the doctors did not realise at the time was that depending on how they drew the hole in the middle of the large block the software would either calculate the correct dosage or it would come up with a dosage which was twice as large as was needed. The doctors were legally required to double check the dosage by hand, but they failed to do this and instead just used the dosages calculated by the software. There were several different mistakes that lead to the deaths of several patients and to many other patients developing serious complications. In my opinion the most obvious mistake was the failure to follow procedure and double check the dosages prescribed by the software. If the doctors had just taken the time to check the dosages then it could have saved several people’s lives and the system could have had this bug fixed by its developers.
The next problem seems to be that the software did not meet the technical requirements that were wanted by the technicians. This could have been for a multitude of reasons, such as a technological restriction since this incident occurred in the year 2000 and computer processors might not have been powerful enough to accommodate the features the doctors wanted. Another possibility is that there was a lack of communication between the developers of the software and the doctors. This would explain why the software only allowed for a maximum of four blocks to be placed while the doctors who were the intended end users wanted more functionality.
Finally, the company that developed the software could have spent more time testing the software to make sure that any holes made in the blocks would not lead to large changes in the dosages calculated depending on the way that the hole was drawn. In conclusion this incident was caused by the doctor’s negligence of proper medical procedure and a possible lack of testing during software development.
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