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GBA 517 Case Study # 1 : When Radiation Therapy Kills
Transcript of GBA 517 Case Study # 1 : When Radiation Therapy Kills
Fundamentals of Management Information Systems
Professor Peter Aviles
28 September 2012 Sepel Williams | Tanisha Thomas
Tony Lau | Winnie Wong | Yelena Utrobina What concepts in the chapter are illustrated in this case?
What ethical issues are raised by radiation technology? Question # 1 What management, organization and technology factors that
was responsible for the problems detailed in this case?
Explain the role of each. Question # 2 How would a central reporting agency that
gathered data on radiation-related
accidents help reduce the number of
radiation therapy errors in the future? Question # 4 If you were in charge of designing electronic software for a linear accelerator,
what are some features you would include?
Are there any features you would avoid? Question # 5 Do you feel that any of the groups involved with this issue (hospital administrators, technicians, medical equipment and software manufacturers) should accept the majority of the blame for these incidents? Question # 3 Radiation Overdoses
Emerging issue Standardize
Instill a safety culture How can data be used to help? Summary Radiation therapy is an advanced technology that can effectively kill deadly cancer cells.
In the case of Scott Jerome-Parks and Alexandra Jn-Charles, both patients in NYC hospitals, suffered terrible deaths due to carelessness of technicians, complex use of software, faulty machines, and poor state regulations.
Mr. Jerome-Parks was treated for tongue cancer by using a newer linear accelerator which was the multi-leaf collimator. Due to the software's crashes, the medical physicist thought the saved radiation treatment plan was updated when it fact it was not. Mr. Jerome-Parks had 7x the prescribed amount of radiation and the multi-leaf collimator was wide open, exposing his whole neck.
Mrs. Jn-Charles was treated for breast cancer and had 28 sessions with a device known as a "wedge." For the first 27 sessions, technicians failed to notice an error message that the wedge was missing, which lead to radiation overdose. What are the responses? Design software with the technicians need in mind.
Need to be able to simultaneously include the technicians so they are aware of what is happening at all times.
A check list on the screen that allows the technicians to double check and guarantee they would monitor the screen when necessary.
A fail-safe mechanism should be put in place. Include an automatic alert that allows the system to shut down when it exceeds a radiation level that can cause harm to the human body.
Program the system to have every crash sent back to the manufacturing/management firm. Basic concepts covered: Responsibility, Accountability and Liability
Ethical issues: Management failed to regulate the hospitals' overworked staff and for not having safety procedures in place to check their work and enough time to do so.
Organization neglected to budget their time and resources properly for training doctors and medical technicians.
Absence of appropriate updates in software by equipment manufacturers.
The U.S. does not have a Central Reporting and Regulatory agency to report radiation technology errors. Utilize raw data
Aid to change policy and procedures Managers within the MIS Complying with federal & state reporting mandates R&D of unique techniques that reduces personnel time and related costs in processing data, personnel, including mid-level management, senior to junior programmer analysts, provides 24-hour, 7-day support for communications network that will reap the benefits of technological change by building an economical, efficient, and salable and integrated computer system. Three categories of errors:
errors caused by machinery complexity
errors caused by medical personnel that operate such machinery
hospital administration errors. Medical machinery and software manufacturers claim that Hospitals that provide with radiation treatment should be responsible for training their staff to correctly operate radiological equipment.
•Technicians claim that they are understaffed and overworked and that there are no procedures in place that would check accuracy of their work.
•Hospitals on the other hand, claim that manufacturers should be doing better job providing radiation equipment with fail-safe mechanisms. •State Government as a regulator and controller of groups involved in radiation therapy and the one who is majorly responsible for medical errors associated with radiological mistreatment. Industry Response: ASRT (American Society of Radiologic Technologists) members believe solution lies in the Consistency, Accuracy, Responsibility and Excellence in Medical Imaging and Radiation Therapy (CARE S. 3737) bill before the House.
FDA (Food and Drug Administration) sent a letter in 2010 to manufacturers recommending they attend Public Workshops concerning these matters.
Timothy E. Guertin, Varian’s president and chief executive, said in an interview that after the accident, the company warned users to be especially careful when using their equipment, and then distributed new software, with a fail-safe provision. Management
Lack of training of the staff (doctors, technicians & machine operators)
Develop a mandatory machinery checklist for employees
Held individuals more accountable
Implementation an internal incident reporting system
“The complexity of new Linear accelerator technology has not been accompanied by with appropriate updates in software”