The patient's entire neck had been exposed and Mr. . egregious as treating patients for the wrong cancers; in pain. His teeth were falling amounts of radiation they can deliver. For example, he was eventually unable to bre he couldn't swallow, and dosa linear accelerators are unable to alert users when a at the age of 43. mother of two from Brookilarly tragic. A 32-year-old responsibility ultimately rests with the technician, an aggressive form of breast, she was diagnosed with software programmers may not have designed their seemed good after breast surgery and chemotherapy, Further complicating the issue is the fact that the total with only 28 days of radiation treatments left to perform. number of radiation-related accidents each year is On the day of her 28th and final session, technicians. essentially unknown. There is no national medical realized that something had gone wrong. Jn-Charles's patient medical record system, and doctors do not know skin had slowly begun to peel and seemed to resist how much radiation their patients have received in the healing. When the hospital looked into the treatment to past. No single agency exists to collect data across the see why this could have happened, they discovered that country on these accidents, and many states don't even the linear accelerator lacked the crucial command to require that accidents be reported. insert the wedge, which must be programmed by the The lack of a central U.S. reporting and regulatory user. Technicians had failed to notice error messages on agency for radiation therapy means that in the event of a their screens indicating the missing wedge dursages on radiation-related mistake, all of the groups involved are of the 27 sessions. This meant able to avoid ultimate responsibility. Medical machinery exposed to almost quadruple the not and software manufacturers claim that it's the doctors' radiationduringeachofthose27visits.themachines,andthehospitalsresponsibilitytoandmedicaltechniciansresponsibilitytoproper Ms. Jn-Charles's radiation overdose created a wound properly budget time and resources for training. that would not heal despite numerous sessions in a Technicians claim that they are understaffed and hyperbaric chamber and multiple surgeries. Although the overworked, and that there are no procedures in place to wound closed up over a year later, she died shortly check their work and no time to do so even if there were. afterwards. Hospitals claim that the newer machinery lacks the It might seem that the carelessness or laziness of the proper fail-safe mechanisms and that there is no room on medical technicians who administered treatment is already limited budgets for the training that equipment primarily to blame in these cases, but other factors have manufacturers claim is required. contributed just as much. The complexity of new linear Currently, the responsibility for regulating these accelerator technology has not been accompanied with incidents falls upon the states, which vary widely in their appropriate updates in software, training, safety enforcement of reporting. As a result of the dangers assoprocedures, and staffing. St. Vincent's hospital stated ciated with ionizing radiation, the Centers for Medicare \& that system crashes similar to those involved in the Medicaid Services (CMS), a part of the U.S. Department improper therapy for Mr. Jerome-Parks "are not of Health and Human Services, will require the accreditauncommon with the Varian software, and these issues tion of facilities providing advanced imaging services have been communicated to Varian on numerous such as CT, magnetic resonance imaging (MRI), positron Manufacturers of these machines boast that they can non-hospital, freestanding settings beginning January 1 , occasions." safelyadministerradiationtreatmenttomoreandmore2012.ThestateofCaliforniahasmandatedthatfacilities patients each day, but hospitals are rarely able to adjust that furnish CT X-ray services become accredited by July their staffing to handle those workloads or increase the 1,2013. This California law also requires the documentaamount of training technicians receive before using tion of the dose of each CT exam, annual verification of newer machines. Medical technicians incorrectly assume each dose by a medical physicist; and reporting dose that the new systems and software are going to work errors to patients and physicians. In addition, in May, the correctly, but in reality they have not been tested over American College of Radiology (ACR) launched its National Radiology Data Registry (NRDR), a registry Many of these errors could have been detected if the database (the General Radiology Improvement Database machine operators were paying attention. In fact, many [GRID]) that compares radiology facilities regionally and of the reported errors involve mistakes as simple and as nationwide. For the first time, it will be possible to When new expensive medical therapies come along, capable of imaging a tumor in two dimensions and promising to cure people of illness, one would think that projecting straight beams of radiation, newer linear the manufacturers, doctors, and technicians, along with accelerators are capable of modeling cancerous tumors the hospitals and state oversight agencies, would take in three dimensions and shaping beams of radiation to extreme caution in their application and use. Often this conform to those shapes. is not the case. Contemporary radiation therapy offers a One of the most common issues with radiation therapy good example of society failing to anticipate and control is finding ways to destroy cancerous cells while the negative impacts of a technology powerful enough to preserving healthy cells. Using this beam-shaping kill people. technique, radiation doesn't pass through as much For individuals and their families suffering through a healthy tissue to reach the cancerous areas. Hospitals battle with cancer, technical advancements in radiation advertised their new accelerators as being able to treat treatment represent hope and a chance for a healthy, previously untreatable cancers because of the precision cancer-free life. But when these highly complex of the beam-shaping method. Using older machinery, machines used to treat cancers go awry or when cancers that were too close to important bodily medical technicians and doctors fail to follow proper structures were considered too dangerous to treat with safety procedures, it results in suffering worse than radiation due to the imprecision of the equipment. the ailments radiation aims to cure. Overuse of How, then, are radiation-related accidents increasing in radiation presents substantial harm. In the last decade, frequency, given the advances in linear acceleration the number of CT scans in the United States has technology? In the cases of Jerome-Parks and tripled, including CT scans of children. One study Jn-Charles, a combination of machine malfunctions and concluded that of the 72 million CT scans performed user error led to these frightening mistakes. in 2007 alone, an estimated 29,000 future cancers and Jerome-Parks's brain stem and neck were exposed to 14,500 future deaths could develop due to radiation excessive dosages of radiation on three separate exposure. A litany of horror stories underscores the occasions because of a computer error. consequences when hospitals fail to provide safe The linear accelerator used to treat Jerome-Parks is radiation treatment to cancer patients. In many of known as a multi-leaf collimator, a newer, more these horror stories, poor software design, poor powerful model that uses over a hundred metal "leaves" human-machine interfaces, and lack of proper to adjust the shape and strength of the beam. The St. training are root causes of the problems. Vincent's hospital collimator was made by Varian The deaths of Scott Jerome-Parks and Alexandra Medical Systems, a leading supplier of radiation Jn-Charles, both patients of New York City hospitals, equipment. are prime examples of radiation treatments going awry. Dr. Anthony M. Berson, St. Vincent's chief radiation Jerome-Parks worked in southern Manhattan near the oncologist, reworked Mr. Jerome-Parks's radiation site of the World Trade Center attacks, and suspected treatment plan to give more protection to his teeth. Nina that the tongue cancer he developed later was related to Kalach, the medical physicist in charge of implementing toxic dust that he came in contact with after the attacks. Jerome-Parks's radiation treatment plan, used Varian His prognosis was uncertain at first, but he had some software to revise the plan. State records show that as reason to be optimistic, given the quality of the Ms. Kalach was trying to save her work, the computer treatment provided by state-of-the-art linear accelerators began seizing up, displaying an error message. The error at St. Vincent's Hospital, which he selected for his message asked if Ms. Kalach wanted to save her changes treatment. But after receiving erroneous dosages of before the program aborted and she responded that she radiation several times, his condition drastically did. Dr. Berson approved the plan. worsened. Six minutes after another computer crash, the first of For the most part, state-of-the-art liear accelerators do provide effective and safe care for linear accelerators several radioactive beams was turned on, followed by and Americans safely receive an for cancer patients, several additional rounds of radiation the next few days. medical radiation each year. Radiationing amount of After the third treatment, Ms. Kalach ran a test to verify and treat all sorts of cancers, saving many to diagnose that the treatment plan was carried out as prescribed, and in the process, and is administered safely patients' lives found that the multi-leaf collimator, which was supposed all cancer patients. Whereas older mach to over half of to focus the beam precisely on Mr. Jerome-Parks's identify weak imaging facilities across the nation and take corrective action. 3. Do you feel that any of the groups involved with this issue (hospital administrators, technicians, medical Sources: Walt Bogdanich, "Medical Group Urges New Rules on Radiation," The equipment, software manufacturers, and government New York Times, February 4, 2010; "As Technology Surges, Radiation Safeguards agencies) should accept the majority of the blame for Lag," New York Times, January 27, 2010; "Radiation Offers New Cures, and Ways these incidents? Why or why not? to Do Harm," New York Times, January 24, 2010; and "Case Studies: When Medical Radiation Goes Awry," New York Times, January 21, 2010. 4. How would a central reporting agency that gathered Case Study Questions data on radiation-related accidents help reduce the 1. What concepts in the chapter are illustrated in this number of radiation therapy errors in the future? case? What ethical issues are raised by radiation 5. If you were in charge of designing electronic technology? software for a linear accelerator, what are some fea- 2. What people, organization, and technology factors were responsible for the problems detailed in this tures you would include? Are there any features you would avoid? case? Explain the role of each