Ch 8 case study
Therac-25 Radiation Overdoses
What Happened
The Therac-25 was a machine that accidentally gave patients too much radiation because
of a software mistake.
E ects: This caused serious injuries and led to three patient deaths.
Who’s Responsible: The company that made the machine, the programmers, and the
hospitals all share the blame.
Lessons Learned
- Test Software: Always test medical software carefully.
- Study to avoid repeated errors
- Work Together: Engineers and doctors need to communicate better for safety.
Software and design Problems with Therac-25
• Old Software: It used old code that had hidden mistakes.
• Confusing Buttons: The controls were hard to understand.
• Not Enough Testing: They didn’t check for mistakes well.
• Dangerous Bugs: It could give radiation when it shouldn’t have.
• Ignored Changes: It didn’t pay attention to important updates from the operators.
Why So Many Incidents?
• New Problem: Hospitals didn’t know why patients were getting too much radiation.
• Company Denial: The manufacturer said their machine couldn’t cause the issues, but
that wasn’t true.
• Partial Fixes: They made some changes but didn’t x the real problems.
• Ignored Advice: They didn’t listen to safety suggestions from experts.
• FDA Action: The FDA declared the machine defective after ve accidents, but another
accident happened while they were still discussing xes.
Key Lessons from Therac-25
• Normal Mistakes: Small errors can happen in complex machines.
• Big Problems: The issues with Therac-25 were serious and showed carelessness.
• Other Accidents: Similar problems happened when:
• Technicians left patients alone.
• They measured drugs incorrectly.
• They mixed up units like micro-curies and milli-curies.
Responsibility Assignments for Therac-25 Case
• Manufacturer (60%)
Responsibility: They made a dangerous machine and didn’t x known problems.
• Programmer (25%)
Responsibility: They created software with bugs that caused issues and should have
tested it better.
• Hospital/Clinic (15%)
Responsibility: They didn’t train sta properly and trusted the machine without checking
its safety.
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