When Radiation therapy Kills?
Case Study

Mar, 5, 2012

Submitted To: DR. Hassan M. Selim
Prepared by: Group 4
Khaled Al Qubaisi
Waleed Al Zaabi
Ali Al Tamimi
Mohamed Al Jefri
Summary
The new radiation therapy comes with high expected from manufacturers, doctors and technicians a long with the hospitals and state oversight agencies to cure people illness from cancers; however, what if these complex machines show the negative impact of technology and its power to kill people and steal the hope of having a healthy life! Also, in many cases, low software design, poor human – machine interfaces and lack proper training are other reasons of hospital failing to cure people who have cancer.
This case study illustrates how bad radiation therapy machines are and the carelessness of technicians using these machines; both cause people death. Some examples regarding the awry of radiation treatment are the death of Scott Jerome-Parks and Jn-Charles. Jerome-Parks has tongue cancer and after getting dosages of radiation, his illness becomes worse. This is because of machine malfunctions and technicians error in using it. What has happened to him is that his brain and neck has exposed to a big amount of the radiation because of a computer error as technician uses the new multi-leaf collimator. As a result, he has deafness, near blindness, teeth falling out and difficulty in breathing and eventually he died.
The other patient, Jn-Charles, was having aggressive breast cancer and she did surgery and chemotherapy and she had 28 days left to do radiation treatment. However, doctor had forgotten to command the machine to insert the wedge in the older model of multi-leaf collimator that the hospital used. Unfortunately, technician did not notice the error messages for the whole 27th sessions. Jn-Charles was exposed to overdose of the radiation and that cause her death after short time.
These two examples show how horrible the complexity of new linear accelerator technology, carelessness of the technicians, low updates in the software and lack of safety procedures, training and staffing can waist many people lives.
All in all, who to blame for all what happened to many patients who have the hope to be cured! Each party blames the other from medical machinery to hospital to technicians. From the previous, it is the responsibility of the states, as they need to enforce organizations and hospitals to have reports for the radiation therapy and the medical mistakes that happened in each hospital.

The Question and answers
Q1. What concepts in the chapter are illustrated in this case? What ethical issues are raised by radiation technology?

It’s obviously the case address the ethical concepts and our point of view is the problem start when everybody try to transfer the responsibilities to others stakeholder from inside hospital and outside. Nevertheless, there are three moral dimensions were violated in the case and there are as follows:
1.Information right and obligation:
2.Accountabilities and control:
3.System quality:

The ethical issues of using the radiation technology are as follows:

-The carelessness of the medical technicians.
-The complexity of new linear accelerator technology is not yet been train the technicians.
-Safety procedures.
-Staffing (management). 1. What management, organization, and technology factors were responsible for the problems detailed in this case? Explain the role of each. Business Challenges
Business Challenges

Management
Management

Organization
Organization
Business solution
Business solution
Information system
Information system

Technology
Technology

Management: * The lack of a central U.S reporting and regulatory agency for radiation therapy. * The responsibility for regulating these incidents falls upon the state, which vary widely in their enforcement of reporting. Organization: * The hospitals are rarely able to adjust their staffing to handle those workloads or increase the amount of training technicians receive before using newer machines. * Many of the reported errors involve mistakes as simple and as egregious as treating patients for the wrong cancers. * Medical technicians are not forced to check over the settings of the linear accelerators that they are handling, and errors that are introduced to the computer systems early on are difficult to detect. Technology: * The new linear accelerator technology has not accompanied with appropriate updates in software, training, safety procedures, and staffing. * Medical technicians incorrectly assume that the new systems and software are going to work correctly. In reality they have not been tested over long periods of time. Information System: * Total number of radiation related accidents each year are essentially unknown. * No single agency exists to collect data across the country on these accidents, and many states don’t even require that accidents be reported. * The mistakes continued for months in the absence of a system that detected treatment errors such received incorrect dosages that led to other crippling aliments. Business Solution: * The technician, software programmers may not have designed their product with the technician`s needs in mind. Business challenge: * Today`s linear accelerators also lack some of the necessary safeguards given the amounts of radiation that they can deliver. * The same erroneous treatment administered repeatedly, until the technicians and doctors have result is a seriously injured patient. * 2. Do you feel that any of the groups involved with this issue (hospital administrators, technicians, and medical equipment and software manufacturers) should accept the majority of the blame for these incidents? Why or why not? After looking to the case we cannot accept majority of the blame to the one of these group for these incident to following reasons: * Lack of successful collaboration requires an appropriate organizational structure and culture, along with appropriate collaboration technology between the groups involve in the radiation therapy. * There have to be supportive culture and business processes to use collaboration. Follow strict rules, policies and guideline of the U.S healthy authority, which is missing and need to development to have same standards to allow all the provider of technology and user have same understanding. * No information management system establishes as references and database for all groups hospitals and technology provider under control center lead by qualified agency.
4. How would a central reporting agency that gathered data on radiation related accidents help reduce the number of radiation therapy errors in the future?

The implementation of central reporting agency definitely will enhance the quality of treatment of cancer patients and will reduce the repetitive deadly errors. The agency will generate the exact numbers or statistic figures of human mistake, IS complexity, Safety procedures and hospitals managing issues (staffing plan) and this information will support them to tackle all errors or at least reduce it and also to report it officially. Moreover, the agency will ensure to distribute the ethical culture among everybody and it will encouraging the accountability for his or her duties in front of the cancer patients’ especially in medical sector.

5. If you were in charge of designing electronic software for a liner accelerator, what are some features you would include? Are there any features you would avoid?
The most important feature is to control exact numbers of radiation therapy session by improve the accuracy of software and be more friendly use by the technicians. Second, add advance features in the software to identify the type of cancer, which should be treated by linear accelerator. To have all reference reported and accident during treatment, which will have central database with the authority agent in each state and all centers of agency, linked by web base structure.
Avoid any new machine upgrade without permission from the agency to obtain the certification and should the offer intensive traning for hospital staff.