<article>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#article10_01_24_201205</id>
	<title>Radiation Therapy Mistakes Cost Lives</title>
	<author>kdawson</author>
	<datestamp>1264327200000</datestamp>
	<htmltext>jmtpi recommends a long NY Times investigative report about how powerful <a href="http://www.nytimes.com/2010/01/24/health/24radiation.html?pagewanted=all">medical linear accelerators have contributed to at least two deaths</a> in the New York area. Although the mistakes were largely due to human error, buggy software also played a role. <i>"...the records described 621 mistakes from 2001 to 2008... most were minor... The Times found that on 133 occasions, devices used to shape or modulate radiation beams... were left out, wrongly positioned, or otherwise misused. On 284 occasions, radiation missed all or part of its intended target or treated the wrong body part entirely. ... Another patient with stomach cancer was treated for prostate cancer. Fifty patients received radiation intended for someone else, including one brain cancer patient who received radiation intended for breast cancer."</i></htmltext>
<tokenext>jmtpi recommends a long NY Times investigative report about how powerful medical linear accelerators have contributed to at least two deaths in the New York area .
Although the mistakes were largely due to human error , buggy software also played a role .
" ...the records described 621 mistakes from 2001 to 2008... most were minor... The Times found that on 133 occasions , devices used to shape or modulate radiation beams... were left out , wrongly positioned , or otherwise misused .
On 284 occasions , radiation missed all or part of its intended target or treated the wrong body part entirely .
... Another patient with stomach cancer was treated for prostate cancer .
Fifty patients received radiation intended for someone else , including one brain cancer patient who received radiation intended for breast cancer .
"</tokentext>
<sentencetext>jmtpi recommends a long NY Times investigative report about how powerful medical linear accelerators have contributed to at least two deaths in the New York area.
Although the mistakes were largely due to human error, buggy software also played a role.
"...the records described 621 mistakes from 2001 to 2008... most were minor... The Times found that on 133 occasions, devices used to shape or modulate radiation beams... were left out, wrongly positioned, or otherwise misused.
On 284 occasions, radiation missed all or part of its intended target or treated the wrong body part entirely.
... Another patient with stomach cancer was treated for prostate cancer.
Fifty patients received radiation intended for someone else, including one brain cancer patient who received radiation intended for breast cancer.
"</sentencetext>
</article>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884548</id>
	<title>Re:Yeah, I know.</title>
	<author>OldEarthResident</author>
	<datestamp>1264343460000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext>You have my sympathy.
<p>
Here in NHS land, I have found the NHS to be good when faced with known conditions (especially when it's associated with one of the many targets they use internally), but they are far less impressive when faced with unusual symptoms.
</p><p>
I hope your wife gets well again.</p></htmltext>
<tokenext>You have my sympathy .
Here in NHS land , I have found the NHS to be good when faced with known conditions ( especially when it 's associated with one of the many targets they use internally ) , but they are far less impressive when faced with unusual symptoms .
I hope your wife gets well again .</tokentext>
<sentencetext>You have my sympathy.
Here in NHS land, I have found the NHS to be good when faced with known conditions (especially when it's associated with one of the many targets they use internally), but they are far less impressive when faced with unusual symptoms.
I hope your wife gets well again.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883408</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882836</id>
	<title>This has happened before</title>
	<author>Protonk</author>
	<datestamp>1264331640000</datestamp>
	<modclass>Insightful</modclass>
	<modscore>3</modscore>
	<htmltext><a href="http://en.wikipedia.org/wiki/Therac-25" title="wikipedia.org">Therac-25</a> [wikipedia.org] is only the most prominent medical radiation incident from the past 20 years or so.  The IEEE linked at the bottom explores problems with replacing hardware interlocks (mostly <b>literal</b> interlocks) with software interlocks, which fell prey to memory errors, bugs and human intervention.  Tools like this require constant diligence and skepticism, which is nearly impossible to maintain when faced with incentives to update, promote and distribute new technology.  I suspect this will devolve into some meta-discussion about regulation, but look closely at the allegations regarding cover-ups in the Therac-25 case and this article--market response presupposes that customers and investors are informed about errors in products.  Where companies downplay or obfuscate errors of this magnitude, <a href="http://en.wikipedia.org/wiki/Tiebout\_model" title="wikipedia.org">public choice</a> [wikipedia.org] fails.  Regulatory bodies won't work perfectly, but I suspect that their intervention in the market would reduce these errors at some high but acceptable cost (in either monetary terms or terms of new technologies forgone due to the cost of compliance).</htmltext>
<tokenext>Therac-25 [ wikipedia.org ] is only the most prominent medical radiation incident from the past 20 years or so .
The IEEE linked at the bottom explores problems with replacing hardware interlocks ( mostly literal interlocks ) with software interlocks , which fell prey to memory errors , bugs and human intervention .
Tools like this require constant diligence and skepticism , which is nearly impossible to maintain when faced with incentives to update , promote and distribute new technology .
I suspect this will devolve into some meta-discussion about regulation , but look closely at the allegations regarding cover-ups in the Therac-25 case and this article--market response presupposes that customers and investors are informed about errors in products .
Where companies downplay or obfuscate errors of this magnitude , public choice [ wikipedia.org ] fails .
Regulatory bodies wo n't work perfectly , but I suspect that their intervention in the market would reduce these errors at some high but acceptable cost ( in either monetary terms or terms of new technologies forgone due to the cost of compliance ) .</tokentext>
<sentencetext>Therac-25 [wikipedia.org] is only the most prominent medical radiation incident from the past 20 years or so.
The IEEE linked at the bottom explores problems with replacing hardware interlocks (mostly literal interlocks) with software interlocks, which fell prey to memory errors, bugs and human intervention.
Tools like this require constant diligence and skepticism, which is nearly impossible to maintain when faced with incentives to update, promote and distribute new technology.
I suspect this will devolve into some meta-discussion about regulation, but look closely at the allegations regarding cover-ups in the Therac-25 case and this article--market response presupposes that customers and investors are informed about errors in products.
Where companies downplay or obfuscate errors of this magnitude, public choice [wikipedia.org] fails.
Regulatory bodies won't work perfectly, but I suspect that their intervention in the market would reduce these errors at some high but acceptable cost (in either monetary terms or terms of new technologies forgone due to the cost of compliance).</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30888282</id>
	<title>Re:highly trained morons</title>
	<author>Hurricane78</author>
	<datestamp>1264423860000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>2</modscore>
	<htmltext><p>Well, a doctor is only a apothecary with a tiny further training. Who after being finished, assumes that he knows <em>everything</em> and will continue to do so <em>forever</em>. If he does not know it, it does not exist. If he knows no cure, there is no cure.<br>Also they are trained to &ldquo;fix&rdquo; the <em>symptoms</em>. (Which is practice means, to hide them under painkillers, so you can continue to ignore what you&rsquo;re doing wrong.) Finding the causes is only happening in colorful Hollywood productions. In reality, it&rsquo;s actually a taboo. Every time I ask a doctor to find the <em>cause</em>, I get a blank stare, and a &ldquo;can&rsquo;t parse&rdquo; error. Or him telling me that a part of my body is the cause! (WTF? A part of the body an by definition not be the cause.)</p><p>Finding causes... it seems... is what scientists are for.</p></htmltext>
<tokenext>Well , a doctor is only a apothecary with a tiny further training .
Who after being finished , assumes that he knows everything and will continue to do so forever .
If he does not know it , it does not exist .
If he knows no cure , there is no cure.Also they are trained to    fix    the symptoms .
( Which is practice means , to hide them under painkillers , so you can continue to ignore what you    re doing wrong .
) Finding the causes is only happening in colorful Hollywood productions .
In reality , it    s actually a taboo .
Every time I ask a doctor to find the cause , I get a blank stare , and a    can    t parse    error .
Or him telling me that a part of my body is the cause !
( WTF ? A part of the body an by definition not be the cause .
) Finding causes... it seems... is what scientists are for .</tokentext>
<sentencetext>Well, a doctor is only a apothecary with a tiny further training.
Who after being finished, assumes that he knows everything and will continue to do so forever.
If he does not know it, it does not exist.
If he knows no cure, there is no cure.Also they are trained to “fix” the symptoms.
(Which is practice means, to hide them under painkillers, so you can continue to ignore what you’re doing wrong.
) Finding the causes is only happening in colorful Hollywood productions.
In reality, it’s actually a taboo.
Every time I ask a doctor to find the cause, I get a blank stare, and a “can’t parse” error.
Or him telling me that a part of my body is the cause!
(WTF? A part of the body an by definition not be the cause.
)Finding causes... it seems... is what scientists are for.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884244</id>
	<title>I had radiation therapy...</title>
	<author>Anonymous</author>
	<datestamp>1264341120000</datestamp>
	<modclass>Funny</modclass>
	<modscore>4</modscore>
	<htmltext><p>... and stuff like this makes me anxious. I had 30+ zaps to my leg. Initially there was a rather involved simulation to precisely aim the beam. They made a mold to hold my leg in place for the treatments and tattooed targeting dots on my leg.</p><p>They screwed up. It was completely bungled and part of the beam was aimed to go right down the side of my leg, frying the top layer of skin. Within a couple of treatments they adjusted it and just used sharpies to make new targeting dots.</p><p>One day I was lying on the table with my balls in the lead sphere to protect them when over the PA I heard the old Windows error sound. Scared the crap out of me until they told me they only used Windows for their scheduling software.</p></htmltext>
<tokenext>... and stuff like this makes me anxious .
I had 30 + zaps to my leg .
Initially there was a rather involved simulation to precisely aim the beam .
They made a mold to hold my leg in place for the treatments and tattooed targeting dots on my leg.They screwed up .
It was completely bungled and part of the beam was aimed to go right down the side of my leg , frying the top layer of skin .
Within a couple of treatments they adjusted it and just used sharpies to make new targeting dots.One day I was lying on the table with my balls in the lead sphere to protect them when over the PA I heard the old Windows error sound .
Scared the crap out of me until they told me they only used Windows for their scheduling software .</tokentext>
<sentencetext>... and stuff like this makes me anxious.
I had 30+ zaps to my leg.
Initially there was a rather involved simulation to precisely aim the beam.
They made a mold to hold my leg in place for the treatments and tattooed targeting dots on my leg.They screwed up.
It was completely bungled and part of the beam was aimed to go right down the side of my leg, frying the top layer of skin.
Within a couple of treatments they adjusted it and just used sharpies to make new targeting dots.One day I was lying on the table with my balls in the lead sphere to protect them when over the PA I heard the old Windows error sound.
Scared the crap out of me until they told me they only used Windows for their scheduling software.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30888014</id>
	<title>Obviously they didn't pay enough engineers</title>
	<author>mattr</author>
	<datestamp>1264420440000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>IIRC RFID tags are indeed used to track patients against procedures in at least one Japanese hospital system working now. I met the developer, who worked for years on it. He tried to open source it once a decade or more ago, and someone tried to push him off a train platform he was convinced in retaliation for threatening their income. He may try it again now that things are a bit different.<br>I also visited a radiation facility and remember something about them using RFID checks on the patient.<br>It sounds like totally irresponsible procedure design by a fucked up health system run by insurance companies, why my Dad (a cancer surgeon) was glad to get out of it. The kind of things discussed in this thread just should not be happening at all. There is no reason in this age for a single patient to be wrongly irradiated even counting human error. What must have happened is the insurance actuarialists computed statistics of a bad dose compared to the cost of overengineering the entire medical procedure from patient checkin to irradiation. The patients lost. Or can someone give a better reason?</p></htmltext>
<tokenext>IIRC RFID tags are indeed used to track patients against procedures in at least one Japanese hospital system working now .
I met the developer , who worked for years on it .
He tried to open source it once a decade or more ago , and someone tried to push him off a train platform he was convinced in retaliation for threatening their income .
He may try it again now that things are a bit different.I also visited a radiation facility and remember something about them using RFID checks on the patient.It sounds like totally irresponsible procedure design by a fucked up health system run by insurance companies , why my Dad ( a cancer surgeon ) was glad to get out of it .
The kind of things discussed in this thread just should not be happening at all .
There is no reason in this age for a single patient to be wrongly irradiated even counting human error .
What must have happened is the insurance actuarialists computed statistics of a bad dose compared to the cost of overengineering the entire medical procedure from patient checkin to irradiation .
The patients lost .
Or can someone give a better reason ?</tokentext>
<sentencetext>IIRC RFID tags are indeed used to track patients against procedures in at least one Japanese hospital system working now.
I met the developer, who worked for years on it.
He tried to open source it once a decade or more ago, and someone tried to push him off a train platform he was convinced in retaliation for threatening their income.
He may try it again now that things are a bit different.I also visited a radiation facility and remember something about them using RFID checks on the patient.It sounds like totally irresponsible procedure design by a fucked up health system run by insurance companies, why my Dad (a cancer surgeon) was glad to get out of it.
The kind of things discussed in this thread just should not be happening at all.
There is no reason in this age for a single patient to be wrongly irradiated even counting human error.
What must have happened is the insurance actuarialists computed statistics of a bad dose compared to the cost of overengineering the entire medical procedure from patient checkin to irradiation.
The patients lost.
Or can someone give a better reason?</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882868</id>
	<title>What is the denominator data?</title>
	<author>Anonymous</author>
	<datestamp>1264331820000</datestamp>
	<modclass>Insightful</modclass>
	<modscore>3</modscore>
	<htmltext><p>These numbers don't mean anything unless we know how many procedures are conducted in total.  It could be that the probability of a fatal complication, defined as (# of fatal complications) / (# of procedures) is quite low.</p><p>I took a course on clinical decision analysis last semester.  Every intervention, even diagnostic ones, carry a risk.  The risk needs to be weighed versus its benefit to determine its overall efficacy.  If the patient is very ill and has a short life expectancy or very low quality of life, then even dangerous procedures become acceptable.</p><p>One can conduct analyses based on expected life expectancy, QALYs (Quality-Adjusted Life Years), QOL (Quality of Life), or from a purely economic point of view.  How much is a patient's life worth?  Is a 5-year-old's life worth more than an 85-year-old's life?  What about a 45-year-old?  This can get quite philosophical.  One could even conduct an analysis against a combination of outcomes, though how we choose to weigh the different outcomes is arbitrary.</p><p>Bayesian probabilities figure heavily into these analyses, and they can give quite counter-intuitive results.  For example, if a test for AIDS is 99\% "accurate" (in terms of sensitivity and specificity), it can still have a very high false positive rate (if AIDS is rare in the general population).  In this sense, the AIDS test carries a toll of emotional devastation for the false positives.  It can be a challenge to convince the general public, even your average physician, of the validity of a model.  A good model will have conducted sensitivity analyses to allow for the possibility that a given procedure may have a higher (or lower) risk than expected.</p></htmltext>
<tokenext>These numbers do n't mean anything unless we know how many procedures are conducted in total .
It could be that the probability of a fatal complication , defined as ( # of fatal complications ) / ( # of procedures ) is quite low.I took a course on clinical decision analysis last semester .
Every intervention , even diagnostic ones , carry a risk .
The risk needs to be weighed versus its benefit to determine its overall efficacy .
If the patient is very ill and has a short life expectancy or very low quality of life , then even dangerous procedures become acceptable.One can conduct analyses based on expected life expectancy , QALYs ( Quality-Adjusted Life Years ) , QOL ( Quality of Life ) , or from a purely economic point of view .
How much is a patient 's life worth ?
Is a 5-year-old 's life worth more than an 85-year-old 's life ?
What about a 45-year-old ?
This can get quite philosophical .
One could even conduct an analysis against a combination of outcomes , though how we choose to weigh the different outcomes is arbitrary.Bayesian probabilities figure heavily into these analyses , and they can give quite counter-intuitive results .
For example , if a test for AIDS is 99 \ % " accurate " ( in terms of sensitivity and specificity ) , it can still have a very high false positive rate ( if AIDS is rare in the general population ) .
In this sense , the AIDS test carries a toll of emotional devastation for the false positives .
It can be a challenge to convince the general public , even your average physician , of the validity of a model .
A good model will have conducted sensitivity analyses to allow for the possibility that a given procedure may have a higher ( or lower ) risk than expected .</tokentext>
<sentencetext>These numbers don't mean anything unless we know how many procedures are conducted in total.
It could be that the probability of a fatal complication, defined as (# of fatal complications) / (# of procedures) is quite low.I took a course on clinical decision analysis last semester.
Every intervention, even diagnostic ones, carry a risk.
The risk needs to be weighed versus its benefit to determine its overall efficacy.
If the patient is very ill and has a short life expectancy or very low quality of life, then even dangerous procedures become acceptable.One can conduct analyses based on expected life expectancy, QALYs (Quality-Adjusted Life Years), QOL (Quality of Life), or from a purely economic point of view.
How much is a patient's life worth?
Is a 5-year-old's life worth more than an 85-year-old's life?
What about a 45-year-old?
This can get quite philosophical.
One could even conduct an analysis against a combination of outcomes, though how we choose to weigh the different outcomes is arbitrary.Bayesian probabilities figure heavily into these analyses, and they can give quite counter-intuitive results.
For example, if a test for AIDS is 99\% "accurate" (in terms of sensitivity and specificity), it can still have a very high false positive rate (if AIDS is rare in the general population).
In this sense, the AIDS test carries a toll of emotional devastation for the false positives.
It can be a challenge to convince the general public, even your average physician, of the validity of a model.
A good model will have conducted sensitivity analyses to allow for the possibility that a given procedure may have a higher (or lower) risk than expected.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30888504</id>
	<title>Re:most of the problems aren't technical</title>
	<author>L4t3r4lu5</author>
	<datestamp>1264426260000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p><div class="quote"><p>Unfortunately there is no system that can eliminate human error, and I'm sure at some point the nurse was told "make sure this shield is in place before treatments".</p></div><p>Why should the nurse be trusted with that procedural requirement? Why couldn't $vendor design their equipment with a simple toggle switch which allowed normal operation with the shield down, and sounded a buzzer (maybe a diagnostic light on the control panel?) when it wasn't locked properly? <b>Rocket surgery it ain't.</b> <br> <br>As usual, though, <i>all</i> equipment is made by the lowest bidder, and saving $0.23 on a pressure switch and and LED is worth it at the risk of getting some faces melted.</p></div>
	</htmltext>
<tokenext>Unfortunately there is no system that can eliminate human error , and I 'm sure at some point the nurse was told " make sure this shield is in place before treatments " .Why should the nurse be trusted with that procedural requirement ?
Why could n't $ vendor design their equipment with a simple toggle switch which allowed normal operation with the shield down , and sounded a buzzer ( maybe a diagnostic light on the control panel ?
) when it was n't locked properly ?
Rocket surgery it ai n't .
As usual , though , all equipment is made by the lowest bidder , and saving $ 0.23 on a pressure switch and and LED is worth it at the risk of getting some faces melted .</tokentext>
<sentencetext>Unfortunately there is no system that can eliminate human error, and I'm sure at some point the nurse was told "make sure this shield is in place before treatments".Why should the nurse be trusted with that procedural requirement?
Why couldn't $vendor design their equipment with a simple toggle switch which allowed normal operation with the shield down, and sounded a buzzer (maybe a diagnostic light on the control panel?
) when it wasn't locked properly?
Rocket surgery it ain't.
As usual, though, all equipment is made by the lowest bidder, and saving $0.23 on a pressure switch and and LED is worth it at the risk of getting some faces melted.
	</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884160</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30890746</id>
	<title>Re:highly trained morons</title>
	<author>mr crypto</author>
	<datestamp>1264437660000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>I actually develop software for radiation oncology.  I had mixed feelings when I read the article - it heavily stressed the errors and briefly mentioned that RO saves many lives.  Our group is a little more advanced than most, and we have extra checks (such as doing a dry run for every patient: irradiating a sensor matrix before the actual patient).  I agree with the article that errors need to be discussed, and in fact our head of research is trying to convince the RO community that we should follow the airlines model (where lives are also on the line) of studying errors, determining root causes, and improving process to avoid them.</p><p>There is always tension in our industry between having the latest techniques available and having reliable treatment procedures, and it's tough to draw the line.  Please don't condemn the field as a whole, but instead push for an environment where if someone makes a mistake, it is handled in a way that improves the system.  Most of the professionals in this field have 10+ years of college and great aspirations of saving lives, but they're all human.  If they are crucified for making a single error, then a culture of covering up will become more entrenched.  If you think that mistakes should never happen, then I'd like take away your backspace key.</p></htmltext>
<tokenext>I actually develop software for radiation oncology .
I had mixed feelings when I read the article - it heavily stressed the errors and briefly mentioned that RO saves many lives .
Our group is a little more advanced than most , and we have extra checks ( such as doing a dry run for every patient : irradiating a sensor matrix before the actual patient ) .
I agree with the article that errors need to be discussed , and in fact our head of research is trying to convince the RO community that we should follow the airlines model ( where lives are also on the line ) of studying errors , determining root causes , and improving process to avoid them.There is always tension in our industry between having the latest techniques available and having reliable treatment procedures , and it 's tough to draw the line .
Please do n't condemn the field as a whole , but instead push for an environment where if someone makes a mistake , it is handled in a way that improves the system .
Most of the professionals in this field have 10 + years of college and great aspirations of saving lives , but they 're all human .
If they are crucified for making a single error , then a culture of covering up will become more entrenched .
If you think that mistakes should never happen , then I 'd like take away your backspace key .</tokentext>
<sentencetext>I actually develop software for radiation oncology.
I had mixed feelings when I read the article - it heavily stressed the errors and briefly mentioned that RO saves many lives.
Our group is a little more advanced than most, and we have extra checks (such as doing a dry run for every patient: irradiating a sensor matrix before the actual patient).
I agree with the article that errors need to be discussed, and in fact our head of research is trying to convince the RO community that we should follow the airlines model (where lives are also on the line) of studying errors, determining root causes, and improving process to avoid them.There is always tension in our industry between having the latest techniques available and having reliable treatment procedures, and it's tough to draw the line.
Please don't condemn the field as a whole, but instead push for an environment where if someone makes a mistake, it is handled in a way that improves the system.
Most of the professionals in this field have 10+ years of college and great aspirations of saving lives, but they're all human.
If they are crucified for making a single error, then a culture of covering up will become more entrenched.
If you think that mistakes should never happen, then I'd like take away your backspace key.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30886518</id>
	<title>Re:Yeah, I know.</title>
	<author>pydev</author>
	<datestamp>1264359180000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>I'm sorry about your wife and I hope she's going to be OK.  However, medicine and surgery are not risk free: there's a good chance that you're going to come out the hospital worse than when you went in.  That's because no human activity is without error.  Unless there's clear negligence or malice on the part of the doctor, it's unavoidable that accidents happen.</p></htmltext>
<tokenext>I 'm sorry about your wife and I hope she 's going to be OK. However , medicine and surgery are not risk free : there 's a good chance that you 're going to come out the hospital worse than when you went in .
That 's because no human activity is without error .
Unless there 's clear negligence or malice on the part of the doctor , it 's unavoidable that accidents happen .</tokentext>
<sentencetext>I'm sorry about your wife and I hope she's going to be OK.  However, medicine and surgery are not risk free: there's a good chance that you're going to come out the hospital worse than when you went in.
That's because no human activity is without error.
Unless there's clear negligence or malice on the part of the doctor, it's unavoidable that accidents happen.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883408</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883678</id>
	<title>Re:Therac-25</title>
	<author>mr exploiter</author>
	<datestamp>1264337160000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>Actually it was more than 2. Wikipedia is not always right.</p></htmltext>
<tokenext>Actually it was more than 2 .
Wikipedia is not always right .</tokentext>
<sentencetext>Actually it was more than 2.
Wikipedia is not always right.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882824</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882756</id>
	<title>Windows as usual.</title>
	<author>Ethanol-fueled</author>
	<datestamp>1264331100000</datestamp>
	<modclass>Troll</modclass>
	<modscore>0</modscore>
	<htmltext>TFA:<blockquote><div><p>When the computer kept crashing, Ms. Kalach, the medical physicist, did not realize that her instructions for the collimator had not been saved, state records show. She proceeded as though the problem had been fixed...<br> <br><nobr> <wbr></nobr>...Shortly after 11 a.m., as Ms. Kalach was trying to save her work, the computer began seizing up, displaying an error message. The hospital would later say that similar system crashes "are not uncommon with the Varian software, and these issues have been communicated to Varian on numerous occasions."</p></div></blockquote><p>

Surprise, surprise. A little link-jumping through the manufacturer's <a href="http://www.varian.com/us/oncology/radiation\_oncology/" title="varian.com" rel="nofollow">products</a> [varian.com] and job openings reveal<nobr> <wbr></nobr>.NET on Win32.<br> <br>

Or could somebody prove that the machines themselves run Linux or some kind of other embedded OS?</p></div>
	</htmltext>
<tokenext>TFA : When the computer kept crashing , Ms. Kalach , the medical physicist , did not realize that her instructions for the collimator had not been saved , state records show .
She proceeded as though the problem had been fixed... ...Shortly after 11 a.m. , as Ms. Kalach was trying to save her work , the computer began seizing up , displaying an error message .
The hospital would later say that similar system crashes " are not uncommon with the Varian software , and these issues have been communicated to Varian on numerous occasions .
" Surprise , surprise .
A little link-jumping through the manufacturer 's products [ varian.com ] and job openings reveal .NET on Win32 .
Or could somebody prove that the machines themselves run Linux or some kind of other embedded OS ?</tokentext>
<sentencetext>TFA:When the computer kept crashing, Ms. Kalach, the medical physicist, did not realize that her instructions for the collimator had not been saved, state records show.
She proceeded as though the problem had been fixed...  ...Shortly after 11 a.m., as Ms. Kalach was trying to save her work, the computer began seizing up, displaying an error message.
The hospital would later say that similar system crashes "are not uncommon with the Varian software, and these issues have been communicated to Varian on numerous occasions.
"

Surprise, surprise.
A little link-jumping through the manufacturer's products [varian.com] and job openings reveal .NET on Win32.
Or could somebody prove that the machines themselves run Linux or some kind of other embedded OS?
	</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883284</id>
	<title>Re:most of the problems aren't technical</title>
	<author>fuzzyfuzzyfungus</author>
	<datestamp>1264334880000</datestamp>
	<modclass>Insightful</modclass>
	<modscore>5</modscore>
	<htmltext>Blaming software isn't the answer(outside of specific software bugs); but blaming humans, while fun and morally satisfying, is also dubiously useful from the perspective of the system as a whole(this does not, of course, mean that you should feel any compunction about sacking egregious cases).<br> <br>

For instance: The radiation shield/guide setup. Yeah, the nurse should have installed it, and she fucked up. However, it is a basic fact of humans that all of them fuck up from time to time, some more than others, and more under some conditions than others. Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the <i>system as a whole</i> very much. Instead, such safety critical systems should be designed to take human error into account. Routine use of checklists, for instance, has been demonstrated to reduce human error. Or, for the more high tech approach, the Radiotherapy machine could have a few extra sensors(RFID and optointerrupters) and the shield and guide units could be RFID tagged. If the machine does not detect the presence of the correct guides in the correct locations, it alerts the operators and refuses to provide a beam.<br> <br>

Humans are flawed, often annoyingly so; but they are what we have to work with. Luckily, it is possible to systematically characterize the form of flawedness exhibited by humans(eg. limits of short and long term memory, probability of making an error on a procedure of given complexity as a function of experience, and so forth) and design systems that, as much as possible, are resistant to those errors. This requires a combination of organizational changes(eg. control of working hours, verification of nonimpairment for critical staff, enforced use of checklists and procedures, firing atypically unreliable staff) and technological changes(substitution of highly reliable barcodes/RFIDs for unreliable handwriting, automated sanity checking, marking patients before surgery, machines that refuse to operate unless their interlock conditions are met, etc.)<br> <br>

Some of this is just a matter of time, some of it will piss off doctors, and some of it will probably piss off patients; but building reliable systems is possible.</htmltext>
<tokenext>Blaming software is n't the answer ( outside of specific software bugs ) ; but blaming humans , while fun and morally satisfying , is also dubiously useful from the perspective of the system as a whole ( this does not , of course , mean that you should feel any compunction about sacking egregious cases ) .
For instance : The radiation shield/guide setup .
Yeah , the nurse should have installed it , and she fucked up .
However , it is a basic fact of humans that all of them fuck up from time to time , some more than others , and more under some conditions than others .
Unless that particular nurse has an atypically bad record for forgetting , it is unlikely that firing her will improve the quality of the system as a whole very much .
Instead , such safety critical systems should be designed to take human error into account .
Routine use of checklists , for instance , has been demonstrated to reduce human error .
Or , for the more high tech approach , the Radiotherapy machine could have a few extra sensors ( RFID and optointerrupters ) and the shield and guide units could be RFID tagged .
If the machine does not detect the presence of the correct guides in the correct locations , it alerts the operators and refuses to provide a beam .
Humans are flawed , often annoyingly so ; but they are what we have to work with .
Luckily , it is possible to systematically characterize the form of flawedness exhibited by humans ( eg .
limits of short and long term memory , probability of making an error on a procedure of given complexity as a function of experience , and so forth ) and design systems that , as much as possible , are resistant to those errors .
This requires a combination of organizational changes ( eg .
control of working hours , verification of nonimpairment for critical staff , enforced use of checklists and procedures , firing atypically unreliable staff ) and technological changes ( substitution of highly reliable barcodes/RFIDs for unreliable handwriting , automated sanity checking , marking patients before surgery , machines that refuse to operate unless their interlock conditions are met , etc .
) Some of this is just a matter of time , some of it will piss off doctors , and some of it will probably piss off patients ; but building reliable systems is possible .</tokentext>
<sentencetext>Blaming software isn't the answer(outside of specific software bugs); but blaming humans, while fun and morally satisfying, is also dubiously useful from the perspective of the system as a whole(this does not, of course, mean that you should feel any compunction about sacking egregious cases).
For instance: The radiation shield/guide setup.
Yeah, the nurse should have installed it, and she fucked up.
However, it is a basic fact of humans that all of them fuck up from time to time, some more than others, and more under some conditions than others.
Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the system as a whole very much.
Instead, such safety critical systems should be designed to take human error into account.
Routine use of checklists, for instance, has been demonstrated to reduce human error.
Or, for the more high tech approach, the Radiotherapy machine could have a few extra sensors(RFID and optointerrupters) and the shield and guide units could be RFID tagged.
If the machine does not detect the presence of the correct guides in the correct locations, it alerts the operators and refuses to provide a beam.
Humans are flawed, often annoyingly so; but they are what we have to work with.
Luckily, it is possible to systematically characterize the form of flawedness exhibited by humans(eg.
limits of short and long term memory, probability of making an error on a procedure of given complexity as a function of experience, and so forth) and design systems that, as much as possible, are resistant to those errors.
This requires a combination of organizational changes(eg.
control of working hours, verification of nonimpairment for critical staff, enforced use of checklists and procedures, firing atypically unreliable staff) and technological changes(substitution of highly reliable barcodes/RFIDs for unreliable handwriting, automated sanity checking, marking patients before surgery, machines that refuse to operate unless their interlock conditions are met, etc.
) 

Some of this is just a matter of time, some of it will piss off doctors, and some of it will probably piss off patients; but building reliable systems is possible.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883034</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884850</id>
	<title>Re:Yeah, I know.</title>
	<author>Anonymous</author>
	<datestamp>1264345200000</datestamp>
	<modclass>Insightful</modclass>
	<modscore>4</modscore>
	<htmltext><p><div class="quote"><p>These "Highly Trained Morons" are working on killing my wife. She went in for a Hysterectomy and ended up with her ureter sutured or cauterized shut resulting in her kidney backing up and shutting down. Now she has a tube out her back  to keep her kidney alive and in a few weeks they'll go in an cut her ureter above the blockage and reattach it to her bladder. All for the low, low, price of $$$$$$$$$$$$. Meanwhile, the nursing staff and E/R staff have done everything in their power to see how much additional damage they can do. No one has any common sense or care that I can see. I'm fit to be tied!</p></div><p>If you survive a hospital stay for anything serious, it's either luck or because you had reasonably intelligent friends and family looking out for you the whole time.  Heaven help anyone without such a network of support.  It helps if they're taking notes -- keeping their own charts, as it were.  Twist all the arms you can, call in all your chips, and good luck.</p></div>
	</htmltext>
<tokenext>These " Highly Trained Morons " are working on killing my wife .
She went in for a Hysterectomy and ended up with her ureter sutured or cauterized shut resulting in her kidney backing up and shutting down .
Now she has a tube out her back to keep her kidney alive and in a few weeks they 'll go in an cut her ureter above the blockage and reattach it to her bladder .
All for the low , low , price of $ $ $ $ $ $ $ $ $ $ $ $ .
Meanwhile , the nursing staff and E/R staff have done everything in their power to see how much additional damage they can do .
No one has any common sense or care that I can see .
I 'm fit to be tied ! If you survive a hospital stay for anything serious , it 's either luck or because you had reasonably intelligent friends and family looking out for you the whole time .
Heaven help anyone without such a network of support .
It helps if they 're taking notes -- keeping their own charts , as it were .
Twist all the arms you can , call in all your chips , and good luck .</tokentext>
<sentencetext>These "Highly Trained Morons" are working on killing my wife.
She went in for a Hysterectomy and ended up with her ureter sutured or cauterized shut resulting in her kidney backing up and shutting down.
Now she has a tube out her back  to keep her kidney alive and in a few weeks they'll go in an cut her ureter above the blockage and reattach it to her bladder.
All for the low, low, price of $$$$$$$$$$$$.
Meanwhile, the nursing staff and E/R staff have done everything in their power to see how much additional damage they can do.
No one has any common sense or care that I can see.
I'm fit to be tied!If you survive a hospital stay for anything serious, it's either luck or because you had reasonably intelligent friends and family looking out for you the whole time.
Heaven help anyone without such a network of support.
It helps if they're taking notes -- keeping their own charts, as it were.
Twist all the arms you can, call in all your chips, and good luck.
	</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883408</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883460</id>
	<title>Re:What is the denominator data?</title>
	<author>registrar</author>
	<datestamp>1264335960000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p><div class="quote"><p>Is a 5-year-old's life worth more than an 85-year-old's life? What about a 45-year-old?  This can get quite philosophical.</p></div><p>Yeah, especially if you think that utilitarianism is the only moral philosophy.  Some of us think that the moral cost of removing a person's only functioning kidney is rather more than the economic cost associated with their death.</p></div>
	</htmltext>
<tokenext>Is a 5-year-old 's life worth more than an 85-year-old 's life ?
What about a 45-year-old ?
This can get quite philosophical.Yeah , especially if you think that utilitarianism is the only moral philosophy .
Some of us think that the moral cost of removing a person 's only functioning kidney is rather more than the economic cost associated with their death .</tokentext>
<sentencetext>Is a 5-year-old's life worth more than an 85-year-old's life?
What about a 45-year-old?
This can get quite philosophical.Yeah, especially if you think that utilitarianism is the only moral philosophy.
Some of us think that the moral cost of removing a person's only functioning kidney is rather more than the economic cost associated with their death.
	</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882868</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883572</id>
	<title>Re:What is the denominator data?</title>
	<author>Mr. Freeman</author>
	<datestamp>1264336560000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext>"It could be that the probability of a fatal complication, defined as (# of fatal complications) / (# of procedures) is quite low."<br><br>It doesn't matter how low the numbers are, anything above ZERO mistakes is BAD, period!  We're not talking about the risks of radiation therapy here.  We're talking about the risks of IDIOTS FUCKING SHIT UP!  These people didn't die because the radiation didn't work, they died because some dipshit didn't use the machine correctly.  It's the same thing as a surgeon cutting out someone's heart when they should have been removing the pancreas.<br><br>Regardless of how risky anything is, every attempt should be made to make it LESS risky.  As safe as possible.  No, it won't ever hit 100\% success, but we should make every attempt to get it as close as possible.</htmltext>
<tokenext>" It could be that the probability of a fatal complication , defined as ( # of fatal complications ) / ( # of procedures ) is quite low .
" It does n't matter how low the numbers are , anything above ZERO mistakes is BAD , period !
We 're not talking about the risks of radiation therapy here .
We 're talking about the risks of IDIOTS FUCKING SHIT UP !
These people did n't die because the radiation did n't work , they died because some dipshit did n't use the machine correctly .
It 's the same thing as a surgeon cutting out someone 's heart when they should have been removing the pancreas.Regardless of how risky anything is , every attempt should be made to make it LESS risky .
As safe as possible .
No , it wo n't ever hit 100 \ % success , but we should make every attempt to get it as close as possible .</tokentext>
<sentencetext>"It could be that the probability of a fatal complication, defined as (# of fatal complications) / (# of procedures) is quite low.
"It doesn't matter how low the numbers are, anything above ZERO mistakes is BAD, period!
We're not talking about the risks of radiation therapy here.
We're talking about the risks of IDIOTS FUCKING SHIT UP!
These people didn't die because the radiation didn't work, they died because some dipshit didn't use the machine correctly.
It's the same thing as a surgeon cutting out someone's heart when they should have been removing the pancreas.Regardless of how risky anything is, every attempt should be made to make it LESS risky.
As safe as possible.
No, it won't ever hit 100\% success, but we should make every attempt to get it as close as possible.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882868</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884070</id>
	<title>Re:most of the problems aren't technical</title>
	<author>anorlunda</author>
	<datestamp>1264339680000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>3</modscore>
	<htmltext><p>The article mentions that safeguards and procedures were ignored.   Before calling for new rules, new procedures, new designs, it would be wise to force existing safeguards to be used without exception.</p><p>Perhaps a conviction or two for negligent homicide against the doctors, nurses, administrators and vendors might get their attention.</p></htmltext>
<tokenext>The article mentions that safeguards and procedures were ignored .
Before calling for new rules , new procedures , new designs , it would be wise to force existing safeguards to be used without exception.Perhaps a conviction or two for negligent homicide against the doctors , nurses , administrators and vendors might get their attention .</tokentext>
<sentencetext>The article mentions that safeguards and procedures were ignored.
Before calling for new rules, new procedures, new designs, it would be wise to force existing safeguards to be used without exception.Perhaps a conviction or two for negligent homicide against the doctors, nurses, administrators and vendors might get their attention.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883284</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882852</id>
	<title>Cancer therapy is dangerous</title>
	<author>MichaelSmith</author>
	<datestamp>1264331760000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>4</modscore>
	<htmltext><p>The whole point is to kill part of the body but a lot of the time this involves almost killing the rest of the body. My wife's father died because he had a rare sensitivity to a chemotherapy drug. They kept going back to the hospital and saying "it feels like this is killing him" and the hospital people would say "yes, that's normal, everybody thinks that". And by the time they realised it really was killing him he had no bone marrow left at all, which is fatal. In that case the problem could have been identified if more people were on the ball, but in practice they are just doing their jobs, going through the motions.</p><p>Its a bit different in technology. Normally when you (say) shut down a server you can check which server you are shutting down first and triple check it. Sure, if data has been left in a machine and you didn't check then thats a problem. But more commonly in medicine its a case of "lets try this, it might work" with no opportunity to check along the way.</p></htmltext>
<tokenext>The whole point is to kill part of the body but a lot of the time this involves almost killing the rest of the body .
My wife 's father died because he had a rare sensitivity to a chemotherapy drug .
They kept going back to the hospital and saying " it feels like this is killing him " and the hospital people would say " yes , that 's normal , everybody thinks that " .
And by the time they realised it really was killing him he had no bone marrow left at all , which is fatal .
In that case the problem could have been identified if more people were on the ball , but in practice they are just doing their jobs , going through the motions.Its a bit different in technology .
Normally when you ( say ) shut down a server you can check which server you are shutting down first and triple check it .
Sure , if data has been left in a machine and you did n't check then thats a problem .
But more commonly in medicine its a case of " lets try this , it might work " with no opportunity to check along the way .</tokentext>
<sentencetext>The whole point is to kill part of the body but a lot of the time this involves almost killing the rest of the body.
My wife's father died because he had a rare sensitivity to a chemotherapy drug.
They kept going back to the hospital and saying "it feels like this is killing him" and the hospital people would say "yes, that's normal, everybody thinks that".
And by the time they realised it really was killing him he had no bone marrow left at all, which is fatal.
In that case the problem could have been identified if more people were on the ball, but in practice they are just doing their jobs, going through the motions.Its a bit different in technology.
Normally when you (say) shut down a server you can check which server you are shutting down first and triple check it.
Sure, if data has been left in a machine and you didn't check then thats a problem.
But more commonly in medicine its a case of "lets try this, it might work" with no opportunity to check along the way.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882778</id>
	<title>Breaking news</title>
	<author>Anonymous</author>
	<datestamp>1264331220000</datestamp>
	<modclass>Insightful</modclass>
	<modscore>4</modscore>
	<htmltext><p>People make mistakes with technology which results in unintended consequences. Giving someone treatment for the wrong disease may have adverse side effects.</p><p>Basically this only proves that people are stupid in general. I don't see anything wrong with this technology.</p></htmltext>
<tokenext>People make mistakes with technology which results in unintended consequences .
Giving someone treatment for the wrong disease may have adverse side effects.Basically this only proves that people are stupid in general .
I do n't see anything wrong with this technology .</tokentext>
<sentencetext>People make mistakes with technology which results in unintended consequences.
Giving someone treatment for the wrong disease may have adverse side effects.Basically this only proves that people are stupid in general.
I don't see anything wrong with this technology.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884938</id>
	<title>responsibility for competency in life-or-death sit</title>
	<author>SuperBanana</author>
	<datestamp>1264345800000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p> <i>Yeah, the nurse should have installed it, and she fucked up. However, it is a basic fact of humans that all of them fuck up from time to time, some more than others, and more under some conditions than others. Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the system as a whole very much. Instead, such safety critical systems should be designed to take human error into account. Routine use of checklists, for instance, has been demonstrated to reduce human error.</i>

</p><p>When the failure could or WILL result in the patient dying, that nurse is aware of the consequences and should take whatever steps THEY feel is necessary to make sure THEY get it done.

</p><p>It's not society's place to shepherd those who hold the lives of others in their hands.  If you can't recognize the importance of something and make sure you follow proper procedure, you're undeserving of the job.</p></htmltext>
<tokenext>Yeah , the nurse should have installed it , and she fucked up .
However , it is a basic fact of humans that all of them fuck up from time to time , some more than others , and more under some conditions than others .
Unless that particular nurse has an atypically bad record for forgetting , it is unlikely that firing her will improve the quality of the system as a whole very much .
Instead , such safety critical systems should be designed to take human error into account .
Routine use of checklists , for instance , has been demonstrated to reduce human error .
When the failure could or WILL result in the patient dying , that nurse is aware of the consequences and should take whatever steps THEY feel is necessary to make sure THEY get it done .
It 's not society 's place to shepherd those who hold the lives of others in their hands .
If you ca n't recognize the importance of something and make sure you follow proper procedure , you 're undeserving of the job .</tokentext>
<sentencetext> Yeah, the nurse should have installed it, and she fucked up.
However, it is a basic fact of humans that all of them fuck up from time to time, some more than others, and more under some conditions than others.
Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the system as a whole very much.
Instead, such safety critical systems should be designed to take human error into account.
Routine use of checklists, for instance, has been demonstrated to reduce human error.
When the failure could or WILL result in the patient dying, that nurse is aware of the consequences and should take whatever steps THEY feel is necessary to make sure THEY get it done.
It's not society's place to shepherd those who hold the lives of others in their hands.
If you can't recognize the importance of something and make sure you follow proper procedure, you're undeserving of the job.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883284</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884034</id>
	<title>Re:Yeah, I know.</title>
	<author>MobileTatsu-NJG</author>
	<datestamp>1264339500000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>I wish you both the best.</p></htmltext>
<tokenext>I wish you both the best .</tokentext>
<sentencetext>I wish you both the best.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883408</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883172</id>
	<title>Therac had a similar failure mode on PDP-11</title>
	<author>argent</author>
	<datestamp>1264334100000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>I don't know what Varian uses, but the Therac incident involved an embedded PDP-11, probably running RT-11 or RSX-11.</p><p>Purely for trivia fans: RSX-11 was Dave Cutler's first OS, followed by VMS and NT.</p></htmltext>
<tokenext>I do n't know what Varian uses , but the Therac incident involved an embedded PDP-11 , probably running RT-11 or RSX-11.Purely for trivia fans : RSX-11 was Dave Cutler 's first OS , followed by VMS and NT .</tokentext>
<sentencetext>I don't know what Varian uses, but the Therac incident involved an embedded PDP-11, probably running RT-11 or RSX-11.Purely for trivia fans: RSX-11 was Dave Cutler's first OS, followed by VMS and NT.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882756</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30888180</id>
	<title>Buggy software IS a human error!</title>
	<author>Hurricane78</author>
	<datestamp>1264422480000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p><div class="quote"><p>Although the mistakes were largely due to human error, buggy software also played a role.</p></div><p>What the...?<br>And where do you think, that software came from?</p><p>Please hand in your geek card.<br>Just like everyone who thinks that Kasparov lost against a machine, and not against a couple of engineers with a loong time to prepare.</p></div>
	</htmltext>
<tokenext>Although the mistakes were largely due to human error , buggy software also played a role.What the... ? And where do you think , that software came from ? Please hand in your geek card.Just like everyone who thinks that Kasparov lost against a machine , and not against a couple of engineers with a loong time to prepare .</tokentext>
<sentencetext>Although the mistakes were largely due to human error, buggy software also played a role.What the...?And where do you think, that software came from?Please hand in your geek card.Just like everyone who thinks that Kasparov lost against a machine, and not against a couple of engineers with a loong time to prepare.
	</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884460</id>
	<title>Re:Yeah, I know.</title>
	<author>ffreeloader</author>
	<datestamp>1264342680000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>I wish you and your wife the best.  I know from personal experience just how badly the businessmen, err, I mean doctors, in this country can screw up.  My wife and I have both spent many thousands of dollars due to businessmen posing as doctors making mistakes due to arrogance and just flat out not caring for anything but the money they make.</p><p>It's difficult to find a competent, caring doctor these days.</p></htmltext>
<tokenext>I wish you and your wife the best .
I know from personal experience just how badly the businessmen , err , I mean doctors , in this country can screw up .
My wife and I have both spent many thousands of dollars due to businessmen posing as doctors making mistakes due to arrogance and just flat out not caring for anything but the money they make.It 's difficult to find a competent , caring doctor these days .</tokentext>
<sentencetext>I wish you and your wife the best.
I know from personal experience just how badly the businessmen, err, I mean doctors, in this country can screw up.
My wife and I have both spent many thousands of dollars due to businessmen posing as doctors making mistakes due to arrogance and just flat out not caring for anything but the money they make.It's difficult to find a competent, caring doctor these days.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883408</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30886564</id>
	<title>Re:Yeah, I know.</title>
	<author>Anonymous</author>
	<datestamp>1264359840000</datestamp>
	<modclass>Informativ</modclass>
	<modscore>1</modscore>
	<htmltext><p>Damage to the ureter and kidneys is a common complication in hysterectomies.  You were almost certainly told of the possibility in the consent forms.  It happens not because doctors are evil or incompetent, but because surgery is difficult.</p><p>It sounds to me they are doing exactly what they need to be doing in this case: they caught the problem early and they are trying to repair it.</p><p>Your cynicism and attitude are only making things worse.  Work with the staff, be nice, and her chances of a good outcome will go up.</p></htmltext>
<tokenext>Damage to the ureter and kidneys is a common complication in hysterectomies .
You were almost certainly told of the possibility in the consent forms .
It happens not because doctors are evil or incompetent , but because surgery is difficult.It sounds to me they are doing exactly what they need to be doing in this case : they caught the problem early and they are trying to repair it.Your cynicism and attitude are only making things worse .
Work with the staff , be nice , and her chances of a good outcome will go up .</tokentext>
<sentencetext>Damage to the ureter and kidneys is a common complication in hysterectomies.
You were almost certainly told of the possibility in the consent forms.
It happens not because doctors are evil or incompetent, but because surgery is difficult.It sounds to me they are doing exactly what they need to be doing in this case: they caught the problem early and they are trying to repair it.Your cynicism and attitude are only making things worse.
Work with the staff, be nice, and her chances of a good outcome will go up.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883408</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884218</id>
	<title>Happened to me in '82.</title>
	<author>Wyatt Earp</author>
	<datestamp>1264340820000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>2</modscore>
	<htmltext><p>Had radiation go wide during a 6 day cycle, radiation burns and good times. It was picked up the following cycle and "adjusted" for.</p></htmltext>
<tokenext>Had radiation go wide during a 6 day cycle , radiation burns and good times .
It was picked up the following cycle and " adjusted " for .</tokentext>
<sentencetext>Had radiation go wide during a 6 day cycle, radiation burns and good times.
It was picked up the following cycle and "adjusted" for.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30894922</id>
	<title>Re:What is the denominator data?</title>
	<author>sjames</author>
	<datestamp>1264410600000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>This is a bit different. Yes, the stats may show a low risk of death. That just means we shouldn't stop treating people. All things considered, the treatment risks are outweighed by the potential benefits.</p><p>No matter how low the risk, if having techs actually understand what they're doing and making the software not crash and fail to save data (while claiming it has saved the data) can keep someone from being in the unenviable situation of knowing that they have gone from having a serious but treatable medical condition to facing certain death, then it MUST be done.</p></htmltext>
<tokenext>This is a bit different .
Yes , the stats may show a low risk of death .
That just means we should n't stop treating people .
All things considered , the treatment risks are outweighed by the potential benefits.No matter how low the risk , if having techs actually understand what they 're doing and making the software not crash and fail to save data ( while claiming it has saved the data ) can keep someone from being in the unenviable situation of knowing that they have gone from having a serious but treatable medical condition to facing certain death , then it MUST be done .</tokentext>
<sentencetext>This is a bit different.
Yes, the stats may show a low risk of death.
That just means we shouldn't stop treating people.
All things considered, the treatment risks are outweighed by the potential benefits.No matter how low the risk, if having techs actually understand what they're doing and making the software not crash and fail to save data (while claiming it has saved the data) can keep someone from being in the unenviable situation of knowing that they have gone from having a serious but treatable medical condition to facing certain death, then it MUST be done.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882868</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883104</id>
	<title>Re:Not a new problem</title>
	<author>Anonymous</author>
	<datestamp>1264333620000</datestamp>
	<modclass>Funny</modclass>
	<modscore>0</modscore>
	<htmltext><p>Its okay, once the Cylons take over and successfully wipe out humanity(this time around) then these errors will be a thing of the past<nobr> <wbr></nobr>:D</p></htmltext>
<tokenext>Its okay , once the Cylons take over and successfully wipe out humanity ( this time around ) then these errors will be a thing of the past : D</tokentext>
<sentencetext>Its okay, once the Cylons take over and successfully wipe out humanity(this time around) then these errors will be a thing of the past :D</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882802</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883730</id>
	<title>Re:Not a new problem</title>
	<author>QuietLagoon</author>
	<datestamp>1264337400000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><i>This appears in textbooks.</i> <p>

It also appears in <a href="http://www.reviewsonline.com/FATALDEF.htm" title="reviewsonline.com">non-fiction books</a> [reviewsonline.com] about this type of problem.</p></htmltext>
<tokenext>This appears in textbooks .
It also appears in non-fiction books [ reviewsonline.com ] about this type of problem .</tokentext>
<sentencetext>This appears in textbooks.
It also appears in non-fiction books [reviewsonline.com] about this type of problem.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882802</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30886438</id>
	<title>Re:highly trained morons</title>
	<author>Hadlock</author>
	<datestamp>1264358400000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>3</modscore>
	<htmltext><p>Yep, my dad got radiation treatment, he got "gamma knife" treatment for brain cancer. You get a special plastic mesh helmet that is specifically molded to your head (for brain cancer paitents, it's molded to other parts for pancreas or breast cancer, etc paitents), and then there are marker dots on the mesh helmet that align with set lasers in the walls. so your body is properly aligned. Then the actual "gamma knife" is placed in the correct position so it creates a red + sign on the targeted area, which matches up with the plastic mesh helmet. Your name is also written on the helmet, and you fetch your own helmet from the same cubbie each time and put it on your own head. A tech makes sure it's secured and double checks that it's your helmet. Not only are you picking out your helmet, but they cross reference your name, and unless you have a very small head, only your helmet is going to properly fit you. The red + sign isn't going to lay "flat" and the laser dots won't line up. It's at least a triple redundancy mode of failure and it seemed to work pretty well. Added bonus: the table looks like that room in the bond movie where bond goes "you expect me to talk?" and the villan responds "no mr bond, i expect you to die! (maniacal laughter). It's kind of neat to do medicine in a room that looks like a bond villian's secret layer.</p></htmltext>
<tokenext>Yep , my dad got radiation treatment , he got " gamma knife " treatment for brain cancer .
You get a special plastic mesh helmet that is specifically molded to your head ( for brain cancer paitents , it 's molded to other parts for pancreas or breast cancer , etc paitents ) , and then there are marker dots on the mesh helmet that align with set lasers in the walls .
so your body is properly aligned .
Then the actual " gamma knife " is placed in the correct position so it creates a red + sign on the targeted area , which matches up with the plastic mesh helmet .
Your name is also written on the helmet , and you fetch your own helmet from the same cubbie each time and put it on your own head .
A tech makes sure it 's secured and double checks that it 's your helmet .
Not only are you picking out your helmet , but they cross reference your name , and unless you have a very small head , only your helmet is going to properly fit you .
The red + sign is n't going to lay " flat " and the laser dots wo n't line up .
It 's at least a triple redundancy mode of failure and it seemed to work pretty well .
Added bonus : the table looks like that room in the bond movie where bond goes " you expect me to talk ?
" and the villan responds " no mr bond , i expect you to die !
( maniacal laughter ) .
It 's kind of neat to do medicine in a room that looks like a bond villian 's secret layer .</tokentext>
<sentencetext>Yep, my dad got radiation treatment, he got "gamma knife" treatment for brain cancer.
You get a special plastic mesh helmet that is specifically molded to your head (for brain cancer paitents, it's molded to other parts for pancreas or breast cancer, etc paitents), and then there are marker dots on the mesh helmet that align with set lasers in the walls.
so your body is properly aligned.
Then the actual "gamma knife" is placed in the correct position so it creates a red + sign on the targeted area, which matches up with the plastic mesh helmet.
Your name is also written on the helmet, and you fetch your own helmet from the same cubbie each time and put it on your own head.
A tech makes sure it's secured and double checks that it's your helmet.
Not only are you picking out your helmet, but they cross reference your name, and unless you have a very small head, only your helmet is going to properly fit you.
The red + sign isn't going to lay "flat" and the laser dots won't line up.
It's at least a triple redundancy mode of failure and it seemed to work pretty well.
Added bonus: the table looks like that room in the bond movie where bond goes "you expect me to talk?
" and the villan responds "no mr bond, i expect you to die!
(maniacal laughter).
It's kind of neat to do medicine in a room that looks like a bond villian's secret layer.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883020</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882984</id>
	<title>perspective</title>
	<author>wizardforce</author>
	<datestamp>1264332600000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>Linear accelerators have contributed to saving far more lives than these errors have taken.  Fortunately, these kind of errors are comparatively rare and not the menace to health that the summary leads one to believe.</p></htmltext>
<tokenext>Linear accelerators have contributed to saving far more lives than these errors have taken .
Fortunately , these kind of errors are comparatively rare and not the menace to health that the summary leads one to believe .</tokentext>
<sentencetext>Linear accelerators have contributed to saving far more lives than these errors have taken.
Fortunately, these kind of errors are comparatively rare and not the menace to health that the summary leads one to believe.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30886204</id>
	<title>therac 25</title>
	<author>Anonymous</author>
	<datestamp>1264356480000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>Yep..</p></htmltext>
<tokenext>Yep. .</tokentext>
<sentencetext>Yep..</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30893844</id>
	<title>Re:highly trained morons</title>
	<author>Anonymous</author>
	<datestamp>1264449300000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><blockquote><div><p> i can atest to the fact the medical field is populated with a lot of highly trained morons.</p></div></blockquote><p>And your qualifications would be...?</p></div>
	</htmltext>
<tokenext>i can atest to the fact the medical field is populated with a lot of highly trained morons.And your qualifications would be... ?</tokentext>
<sentencetext> i can atest to the fact the medical field is populated with a lot of highly trained morons.And your qualifications would be...?
	</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883034</id>
	<title>most of the problems aren't technical</title>
	<author>Anonymous</author>
	<datestamp>1264333080000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>5</modscore>
	<htmltext><p> <i>This appears in textbooks. Problems like this shouldn't still be happening.</i>

</p><p>They happen because the entire medical system is flawed; look at where many of the errors occurred.  They had nothing to do with software.  If the radiation shield/guide isn't installed, that's not the software's fault.  Don't blame human problems on technical things, and don't solve human problems with technical solutions.  If a nurse forgets to put a radiation shield in place, FIRE THEIR ASS.

</p><p>How flawed is the medical system in the US?

</p><ul>
<li>Doctors are trained by making them work the really shitty hours the older, more experienced doctors don't want to work- and working them to the bone (because they're paid a fixed salary, which is a pittance for the hours they're putting in) so that they're sleep-deprived.  Which is know to interfere with judgment and decision-making processes.  Perfect for diagnostic thinking, right?</li>
<li>Doctors can't be bothered to PRINT clearly on prescription slips, so pharmacies often fill the prescription out incorrectly, or have to call and pester the doctor- who probably doesn't remember what they wrote, and saw so many patients, that they don't remember correctly.</li>
<li>Doctors and surgeons routinely fuck up on the most basic things, like which side of the body they're operating on, often in some VERY serious, permanent operations, like amputations.</li>
<li>Doctors and nurses, time and time again, have been shown to not practice the most simple procedures for infection control, like washing their hands before/after every patient.</li>
<li>A couple of doctors in the Boston area have a)left patients on the operating table (opened up!) to run an errand at the bank b)shown up drunk or high for operations c)been beyond unprofessional to staff 'below' them (screaming, throwing things etc.)</li>
</ul><p>These are people who are some of the most highly paid people in society, who have taken an oath (which the are happy to get uppity about whenever it serves them.)  When they fuck up, their malpractice insurance covers the lawsuit.  And then the doctors turn around and bitch at us about how expensive it is to be a doctor, mostly because of their insane malpractice insurance.

</p><p>Did I mention that everyone goes into obscure specialties, meaning that if you want a Toe Oncologist, you can see one in a few days, but you've got to wait weeks in most major cities for a general practitioner...who just so happens to be the only person who can approve your care if you're on an HMO?</p></htmltext>
<tokenext>This appears in textbooks .
Problems like this should n't still be happening .
They happen because the entire medical system is flawed ; look at where many of the errors occurred .
They had nothing to do with software .
If the radiation shield/guide is n't installed , that 's not the software 's fault .
Do n't blame human problems on technical things , and do n't solve human problems with technical solutions .
If a nurse forgets to put a radiation shield in place , FIRE THEIR ASS .
How flawed is the medical system in the US ?
Doctors are trained by making them work the really shitty hours the older , more experienced doctors do n't want to work- and working them to the bone ( because they 're paid a fixed salary , which is a pittance for the hours they 're putting in ) so that they 're sleep-deprived .
Which is know to interfere with judgment and decision-making processes .
Perfect for diagnostic thinking , right ?
Doctors ca n't be bothered to PRINT clearly on prescription slips , so pharmacies often fill the prescription out incorrectly , or have to call and pester the doctor- who probably does n't remember what they wrote , and saw so many patients , that they do n't remember correctly .
Doctors and surgeons routinely fuck up on the most basic things , like which side of the body they 're operating on , often in some VERY serious , permanent operations , like amputations .
Doctors and nurses , time and time again , have been shown to not practice the most simple procedures for infection control , like washing their hands before/after every patient .
A couple of doctors in the Boston area have a ) left patients on the operating table ( opened up !
) to run an errand at the bank b ) shown up drunk or high for operations c ) been beyond unprofessional to staff 'below ' them ( screaming , throwing things etc .
) These are people who are some of the most highly paid people in society , who have taken an oath ( which the are happy to get uppity about whenever it serves them .
) When they fuck up , their malpractice insurance covers the lawsuit .
And then the doctors turn around and bitch at us about how expensive it is to be a doctor , mostly because of their insane malpractice insurance .
Did I mention that everyone goes into obscure specialties , meaning that if you want a Toe Oncologist , you can see one in a few days , but you 've got to wait weeks in most major cities for a general practitioner...who just so happens to be the only person who can approve your care if you 're on an HMO ?</tokentext>
<sentencetext> This appears in textbooks.
Problems like this shouldn't still be happening.
They happen because the entire medical system is flawed; look at where many of the errors occurred.
They had nothing to do with software.
If the radiation shield/guide isn't installed, that's not the software's fault.
Don't blame human problems on technical things, and don't solve human problems with technical solutions.
If a nurse forgets to put a radiation shield in place, FIRE THEIR ASS.
How flawed is the medical system in the US?
Doctors are trained by making them work the really shitty hours the older, more experienced doctors don't want to work- and working them to the bone (because they're paid a fixed salary, which is a pittance for the hours they're putting in) so that they're sleep-deprived.
Which is know to interfere with judgment and decision-making processes.
Perfect for diagnostic thinking, right?
Doctors can't be bothered to PRINT clearly on prescription slips, so pharmacies often fill the prescription out incorrectly, or have to call and pester the doctor- who probably doesn't remember what they wrote, and saw so many patients, that they don't remember correctly.
Doctors and surgeons routinely fuck up on the most basic things, like which side of the body they're operating on, often in some VERY serious, permanent operations, like amputations.
Doctors and nurses, time and time again, have been shown to not practice the most simple procedures for infection control, like washing their hands before/after every patient.
A couple of doctors in the Boston area have a)left patients on the operating table (opened up!
) to run an errand at the bank b)shown up drunk or high for operations c)been beyond unprofessional to staff 'below' them (screaming, throwing things etc.
)
These are people who are some of the most highly paid people in society, who have taken an oath (which the are happy to get uppity about whenever it serves them.
)  When they fuck up, their malpractice insurance covers the lawsuit.
And then the doctors turn around and bitch at us about how expensive it is to be a doctor, mostly because of their insane malpractice insurance.
Did I mention that everyone goes into obscure specialties, meaning that if you want a Toe Oncologist, you can see one in a few days, but you've got to wait weeks in most major cities for a general practitioner...who just so happens to be the only person who can approve your care if you're on an HMO?</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882802</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30887162</id>
	<title>Re:highly trained morons</title>
	<author>Anonymous</author>
	<datestamp>1264453020000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>2</modscore>
	<htmltext><i>I've done similar things ever since I went in for an operation where they started the incision on the wrong side then decided they'd just go with it and tunnel across my abdomen instead of starting over in the right spot.</i> <p>

Well, they did the right (i.e. least risky) thing. Every hole cut into the bodys line of defense against the hostile exterior is a possible site for an infection, hence you want to keep the number and size of the holes as low as possible.</p></htmltext>
<tokenext>I 've done similar things ever since I went in for an operation where they started the incision on the wrong side then decided they 'd just go with it and tunnel across my abdomen instead of starting over in the right spot .
Well , they did the right ( i.e .
least risky ) thing .
Every hole cut into the bodys line of defense against the hostile exterior is a possible site for an infection , hence you want to keep the number and size of the holes as low as possible .</tokentext>
<sentencetext>I've done similar things ever since I went in for an operation where they started the incision on the wrong side then decided they'd just go with it and tunnel across my abdomen instead of starting over in the right spot.
Well, they did the right (i.e.
least risky) thing.
Every hole cut into the bodys line of defense against the hostile exterior is a possible site for an infection, hence you want to keep the number and size of the holes as low as possible.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883020</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884496</id>
	<title>Re:Breaking news</title>
	<author>SEWilco</author>
	<datestamp>1264342980000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext>Automobile Driving Mistakes Cost Lives.</htmltext>
<tokenext>Automobile Driving Mistakes Cost Lives .</tokentext>
<sentencetext>Automobile Driving Mistakes Cost Lives.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882778</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883822</id>
	<title>Re:Breaking news</title>
	<author>ThrowAwaySociety</author>
	<datestamp>1264338000000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p><div class="quote"><p>People make mistakes with technology which results in unintended consequences. Giving someone treatment for the wrong disease may have adverse side effects.</p><p>Basically this only proves that people are stupid in general. I don't see anything wrong with this technology.</p></div><p>So you don't see a problem with a machine that may be deadly if used improperly, but is too complicated for the intended users to use properly?</p><p>Can you give me an idea of where you live? Because I'd sure love to move to wherever it is that all users are mistake-free geniuses.</p></div>
	</htmltext>
<tokenext>People make mistakes with technology which results in unintended consequences .
Giving someone treatment for the wrong disease may have adverse side effects.Basically this only proves that people are stupid in general .
I do n't see anything wrong with this technology.So you do n't see a problem with a machine that may be deadly if used improperly , but is too complicated for the intended users to use properly ? Can you give me an idea of where you live ?
Because I 'd sure love to move to wherever it is that all users are mistake-free geniuses .</tokentext>
<sentencetext>People make mistakes with technology which results in unintended consequences.
Giving someone treatment for the wrong disease may have adverse side effects.Basically this only proves that people are stupid in general.
I don't see anything wrong with this technology.So you don't see a problem with a machine that may be deadly if used improperly, but is too complicated for the intended users to use properly?Can you give me an idea of where you live?
Because I'd sure love to move to wherever it is that all users are mistake-free geniuses.
	</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882778</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884202</id>
	<title>Re:most of the problems aren't technical</title>
	<author>mjwx</author>
	<datestamp>1264340640000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><blockquote><div><p>Blaming software isn't the answer(outside of specific software bugs); but blaming humans, while fun and morally satisfying, is also dubiously useful from the perspective of the system as a whole(this does not, of course, mean that you should feel any compunction about sacking egregious cases).</p></div></blockquote><p>

I think your post boils down to "blaming is not the answer".<br> <br>

Humans do screw up. What's important is that when humans do make mistakes that the situation is rectified so that mistakes do not happen in the future. This means that we have to investigate what went wrong, this also means that some responsibility must also be taken but pointless finger pointing helps no-one and fails to fix the issue.<br> <br>

Mistakes happen, but the same mistake should not happen twice and it's normally the blame/blame aversion culture that causes this.</p></div>
	</htmltext>
<tokenext>Blaming software is n't the answer ( outside of specific software bugs ) ; but blaming humans , while fun and morally satisfying , is also dubiously useful from the perspective of the system as a whole ( this does not , of course , mean that you should feel any compunction about sacking egregious cases ) .
I think your post boils down to " blaming is not the answer " .
Humans do screw up .
What 's important is that when humans do make mistakes that the situation is rectified so that mistakes do not happen in the future .
This means that we have to investigate what went wrong , this also means that some responsibility must also be taken but pointless finger pointing helps no-one and fails to fix the issue .
Mistakes happen , but the same mistake should not happen twice and it 's normally the blame/blame aversion culture that causes this .</tokentext>
<sentencetext>Blaming software isn't the answer(outside of specific software bugs); but blaming humans, while fun and morally satisfying, is also dubiously useful from the perspective of the system as a whole(this does not, of course, mean that you should feel any compunction about sacking egregious cases).
I think your post boils down to "blaming is not the answer".
Humans do screw up.
What's important is that when humans do make mistakes that the situation is rectified so that mistakes do not happen in the future.
This means that we have to investigate what went wrong, this also means that some responsibility must also be taken but pointless finger pointing helps no-one and fails to fix the issue.
Mistakes happen, but the same mistake should not happen twice and it's normally the blame/blame aversion culture that causes this.
	</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883284</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30885176</id>
	<title>Re:most of the problems aren't technical</title>
	<author>Rob the Bold</author>
	<datestamp>1264347420000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p><div class="quote"><p>Did I mention that everyone goes into obscure specialties, meaning that if you want a Toe Oncologist, you can see one in a few days, but you've got to wait weeks in most major cities for a general practitioner...who just so happens to be the only person who can approve your care if you're on an HMO?</p></div><p>Pay for a GP-- now usually called a Family Practitioner or General Practitioner or Internist -- sucks compared with specializing.  And medical school costs the same regardless of specialty.  Major financial disincentive (at least in US).  You'd think the shortage of GPs would result in higher pay -- free markets and all -- but it doesn't seem to be working in the short run.</p><p>I know what you're writing about.  My wife is a first year resident in family practice.  One of her responsibilities is clearing patients for surgery.  Surgeons can't be counted on to even get the IV orders right, e.g. dextrose IV for a diabetic, so she has to fix those things at 3 AM.   But they work their asses off so the hospitalsts don't have to be disturbed in the middle of the night.</p><p>You <em>can</em> get in to a GP <em>if</em> you can find an in-network residency clinic.  Residents have plenty of free time in clinic hours -- lots of no-shows, etc.  But yeah, that's a big <em>if</em>.</p></div>
	</htmltext>
<tokenext>Did I mention that everyone goes into obscure specialties , meaning that if you want a Toe Oncologist , you can see one in a few days , but you 've got to wait weeks in most major cities for a general practitioner...who just so happens to be the only person who can approve your care if you 're on an HMO ? Pay for a GP-- now usually called a Family Practitioner or General Practitioner or Internist -- sucks compared with specializing .
And medical school costs the same regardless of specialty .
Major financial disincentive ( at least in US ) .
You 'd think the shortage of GPs would result in higher pay -- free markets and all -- but it does n't seem to be working in the short run.I know what you 're writing about .
My wife is a first year resident in family practice .
One of her responsibilities is clearing patients for surgery .
Surgeons ca n't be counted on to even get the IV orders right , e.g .
dextrose IV for a diabetic , so she has to fix those things at 3 AM .
But they work their asses off so the hospitalsts do n't have to be disturbed in the middle of the night.You can get in to a GP if you can find an in-network residency clinic .
Residents have plenty of free time in clinic hours -- lots of no-shows , etc .
But yeah , that 's a big if .</tokentext>
<sentencetext>Did I mention that everyone goes into obscure specialties, meaning that if you want a Toe Oncologist, you can see one in a few days, but you've got to wait weeks in most major cities for a general practitioner...who just so happens to be the only person who can approve your care if you're on an HMO?Pay for a GP-- now usually called a Family Practitioner or General Practitioner or Internist -- sucks compared with specializing.
And medical school costs the same regardless of specialty.
Major financial disincentive (at least in US).
You'd think the shortage of GPs would result in higher pay -- free markets and all -- but it doesn't seem to be working in the short run.I know what you're writing about.
My wife is a first year resident in family practice.
One of her responsibilities is clearing patients for surgery.
Surgeons can't be counted on to even get the IV orders right, e.g.
dextrose IV for a diabetic, so she has to fix those things at 3 AM.
But they work their asses off so the hospitalsts don't have to be disturbed in the middle of the night.You can get in to a GP if you can find an in-network residency clinic.
Residents have plenty of free time in clinic hours -- lots of no-shows, etc.
But yeah, that's a big if.
	</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883034</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30885052</id>
	<title>Re:highly trained morons</title>
	<author>golden age villain</author>
	<datestamp>1264346640000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext>I think that this has to do with the fact that a lot of MDs have little to no understanding of basic science principles, at least around where I live. They have too little basic science training. I remember this course on PET I attended at the Physics Dept. of my University. When the lecturer started to talk about anti-matter, the MDs looked as if they just had been teleported into a Star Trek episode and that is a tool they were using every single day!</htmltext>
<tokenext>I think that this has to do with the fact that a lot of MDs have little to no understanding of basic science principles , at least around where I live .
They have too little basic science training .
I remember this course on PET I attended at the Physics Dept .
of my University .
When the lecturer started to talk about anti-matter , the MDs looked as if they just had been teleported into a Star Trek episode and that is a tool they were using every single day !</tokentext>
<sentencetext>I think that this has to do with the fact that a lot of MDs have little to no understanding of basic science principles, at least around where I live.
They have too little basic science training.
I remember this course on PET I attended at the Physics Dept.
of my University.
When the lecturer started to talk about anti-matter, the MDs looked as if they just had been teleported into a Star Trek episode and that is a tool they were using every single day!</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30886634</id>
	<title>Medical mistakes can kill people</title>
	<author>Legion303</author>
	<datestamp>1264360800000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>In other breaking news: the sun is hot, granite is hard and water is wet.</p></htmltext>
<tokenext>In other breaking news : the sun is hot , granite is hard and water is wet .</tokentext>
<sentencetext>In other breaking news: the sun is hot, granite is hard and water is wet.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884538</id>
	<title>Re:highly trained morons</title>
	<author>Anonymous</author>
	<datestamp>1264343400000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>I recently dislocated my right elbow.  Went to the Dr for a followup and he noticed that whoever filled out the form said it was my left elbow.  Was it dyslexia at work?</p><p>A few years ago, I was working on a mill startup with an electrician.  He said they had an apprentice in their program who was red/green color blind.  Since green is used for ground and red is commonly used for hot, he would get things mixed up.  They suggested he resign, but couldn't do anything outright because of the Americans With Disability Act.</p></htmltext>
<tokenext>I recently dislocated my right elbow .
Went to the Dr for a followup and he noticed that whoever filled out the form said it was my left elbow .
Was it dyslexia at work ? A few years ago , I was working on a mill startup with an electrician .
He said they had an apprentice in their program who was red/green color blind .
Since green is used for ground and red is commonly used for hot , he would get things mixed up .
They suggested he resign , but could n't do anything outright because of the Americans With Disability Act .</tokentext>
<sentencetext>I recently dislocated my right elbow.
Went to the Dr for a followup and he noticed that whoever filled out the form said it was my left elbow.
Was it dyslexia at work?A few years ago, I was working on a mill startup with an electrician.
He said they had an apprentice in their program who was red/green color blind.
Since green is used for ground and red is commonly used for hot, he would get things mixed up.
They suggested he resign, but couldn't do anything outright because of the Americans With Disability Act.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30887888</id>
	<title>Re:highly trained morons</title>
	<author>tsjaikdus</author>
	<datestamp>1264418880000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>I'm not into the medical field, but while in university doing engineering one of my group members put our model against a big sanding machine thereby pretty much evaporating it within 2 seconds. The only think I thought was oh shit those people get medical degrees, too. If I ever get sick I'm screwed.</p></htmltext>
<tokenext>I 'm not into the medical field , but while in university doing engineering one of my group members put our model against a big sanding machine thereby pretty much evaporating it within 2 seconds .
The only think I thought was oh shit those people get medical degrees , too .
If I ever get sick I 'm screwed .</tokentext>
<sentencetext>I'm not into the medical field, but while in university doing engineering one of my group members put our model against a big sanding machine thereby pretty much evaporating it within 2 seconds.
The only think I thought was oh shit those people get medical degrees, too.
If I ever get sick I'm screwed.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884160</id>
	<title>Re:most of the problems aren't technical</title>
	<author>Anonymous</author>
	<datestamp>1264340460000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>2</modscore>
	<htmltext><i>"Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the system as a whole very much. Instead, such safety critical systems should be designed to take human error into account."</i>
<br> <br>
Maybe prosecuting her for murder would help reduce human error?  Do you think saying "humans are flawed, deal with it" helps?
<br> <br>
Unfortunately there is no system that can eliminate human error, and I'm sure at some point the nurse was told "make sure this shield is in place before treatments".  You can put all the checklists and maintenance and safety toggles in place all day but when they ignore the checklist and safety toggles at some point you need to suck it up and start charging people with murder because firing them and sending them to <i>another</i> hospital to kill <i>another</i> patient doesn't really solve the problem does it?
<br> <br>
However I'd agree the system could be improved:  how about requiring a second operator to double-check the machine before the treatment is delivered?  <b>Ultimately it all comes down to money, is it cheaper to just keep killing people or implement a more reliable safety system?</b>  Until it becomes more expensive to kill people then it does to create safety systems they will continue to kill patients.  This is why I support huge lawsuits against doctors and hospitals, because the faster we reach that killing/safety threshold the faster we'll reach a system that saves lives instead of taking them.</htmltext>
<tokenext>" Unless that particular nurse has an atypically bad record for forgetting , it is unlikely that firing her will improve the quality of the system as a whole very much .
Instead , such safety critical systems should be designed to take human error into account .
" Maybe prosecuting her for murder would help reduce human error ?
Do you think saying " humans are flawed , deal with it " helps ?
Unfortunately there is no system that can eliminate human error , and I 'm sure at some point the nurse was told " make sure this shield is in place before treatments " .
You can put all the checklists and maintenance and safety toggles in place all day but when they ignore the checklist and safety toggles at some point you need to suck it up and start charging people with murder because firing them and sending them to another hospital to kill another patient does n't really solve the problem does it ?
However I 'd agree the system could be improved : how about requiring a second operator to double-check the machine before the treatment is delivered ?
Ultimately it all comes down to money , is it cheaper to just keep killing people or implement a more reliable safety system ?
Until it becomes more expensive to kill people then it does to create safety systems they will continue to kill patients .
This is why I support huge lawsuits against doctors and hospitals , because the faster we reach that killing/safety threshold the faster we 'll reach a system that saves lives instead of taking them .</tokentext>
<sentencetext>"Unless that particular nurse has an atypically bad record for forgetting, it is unlikely that firing her will improve the quality of the system as a whole very much.
Instead, such safety critical systems should be designed to take human error into account.
"
 
Maybe prosecuting her for murder would help reduce human error?
Do you think saying "humans are flawed, deal with it" helps?
Unfortunately there is no system that can eliminate human error, and I'm sure at some point the nurse was told "make sure this shield is in place before treatments".
You can put all the checklists and maintenance and safety toggles in place all day but when they ignore the checklist and safety toggles at some point you need to suck it up and start charging people with murder because firing them and sending them to another hospital to kill another patient doesn't really solve the problem does it?
However I'd agree the system could be improved:  how about requiring a second operator to double-check the machine before the treatment is delivered?
Ultimately it all comes down to money, is it cheaper to just keep killing people or implement a more reliable safety system?
Until it becomes more expensive to kill people then it does to create safety systems they will continue to kill patients.
This is why I support huge lawsuits against doctors and hospitals, because the faster we reach that killing/safety threshold the faster we'll reach a system that saves lives instead of taking them.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883284</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882818</id>
	<title>This is scary...</title>
	<author>xQuarkDS9x</author>
	<datestamp>1264331520000</datestamp>
	<modclass>Insightful</modclass>
	<modscore>2</modscore>
	<htmltext><p>This is scary indeed when you are under the assumption that you are going into a hospital or clinic for a treatment like this, and assuming he/she is well trained and know what they are doing to your body... to read something like this makes one wonder just what, if any training they get to operate these machines?</p><p>How did one guy above me put it... Highly trained morons? I have to agree!!!</p></htmltext>
<tokenext>This is scary indeed when you are under the assumption that you are going into a hospital or clinic for a treatment like this , and assuming he/she is well trained and know what they are doing to your body... to read something like this makes one wonder just what , if any training they get to operate these machines ? How did one guy above me put it... Highly trained morons ?
I have to agree ! !
!</tokentext>
<sentencetext>This is scary indeed when you are under the assumption that you are going into a hospital or clinic for a treatment like this, and assuming he/she is well trained and know what they are doing to your body... to read something like this makes one wonder just what, if any training they get to operate these machines?How did one guy above me put it... Highly trained morons?
I have to agree!!
!</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30893612</id>
	<title>Re:Yeah, I know.</title>
	<author>CompMD</author>
	<datestamp>1264447980000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>I wish both of you the best and a speedy recovery to your wife.  My brother had an appendectomy that the doctor screwed up a few years ago.  The doctor ended up stitching up some major nerves and damaged them.  The nerve damage led to near constant intense pain in his lower abdomen and reduced heart function.  Thankfully he was on our parents' insurance, and our father works for the government, thus had excellent coverage.  We've fought like hell for him, even getting him into the Mayo Clinic.  That was when I realized how much having family and good people around can help.  Even though we didn't get all the answers we needed at Mayo, the experience of family and doctors banding together to help was a major turning point and improved my brother's morale incredibly.  His heart has improved with treatment now, but there are still days of excruciating pain when even the morphine doesn't help.</p><p>The bottom line is you have to fight.  As someone who has been a professional in two fields, I have respect for the field of medicine.  In general, I have respect for doctors.  But I don't have ANY respect for any professional who doesn't admit their mistakes and causes people to suffer because of them.  The only way to deal with those people is to fight, and fight hard.  Its not a pleasant experience, but you've made it this far, you have to keep going.  Know that right now things may be tight and costs may be high, but some malpractice insurance company and a good lawyer or too can help with that.  Good luck to you both.</p></htmltext>
<tokenext>I wish both of you the best and a speedy recovery to your wife .
My brother had an appendectomy that the doctor screwed up a few years ago .
The doctor ended up stitching up some major nerves and damaged them .
The nerve damage led to near constant intense pain in his lower abdomen and reduced heart function .
Thankfully he was on our parents ' insurance , and our father works for the government , thus had excellent coverage .
We 've fought like hell for him , even getting him into the Mayo Clinic .
That was when I realized how much having family and good people around can help .
Even though we did n't get all the answers we needed at Mayo , the experience of family and doctors banding together to help was a major turning point and improved my brother 's morale incredibly .
His heart has improved with treatment now , but there are still days of excruciating pain when even the morphine does n't help.The bottom line is you have to fight .
As someone who has been a professional in two fields , I have respect for the field of medicine .
In general , I have respect for doctors .
But I do n't have ANY respect for any professional who does n't admit their mistakes and causes people to suffer because of them .
The only way to deal with those people is to fight , and fight hard .
Its not a pleasant experience , but you 've made it this far , you have to keep going .
Know that right now things may be tight and costs may be high , but some malpractice insurance company and a good lawyer or too can help with that .
Good luck to you both .</tokentext>
<sentencetext>I wish both of you the best and a speedy recovery to your wife.
My brother had an appendectomy that the doctor screwed up a few years ago.
The doctor ended up stitching up some major nerves and damaged them.
The nerve damage led to near constant intense pain in his lower abdomen and reduced heart function.
Thankfully he was on our parents' insurance, and our father works for the government, thus had excellent coverage.
We've fought like hell for him, even getting him into the Mayo Clinic.
That was when I realized how much having family and good people around can help.
Even though we didn't get all the answers we needed at Mayo, the experience of family and doctors banding together to help was a major turning point and improved my brother's morale incredibly.
His heart has improved with treatment now, but there are still days of excruciating pain when even the morphine doesn't help.The bottom line is you have to fight.
As someone who has been a professional in two fields, I have respect for the field of medicine.
In general, I have respect for doctors.
But I don't have ANY respect for any professional who doesn't admit their mistakes and causes people to suffer because of them.
The only way to deal with those people is to fight, and fight hard.
Its not a pleasant experience, but you've made it this far, you have to keep going.
Know that right now things may be tight and costs may be high, but some malpractice insurance company and a good lawyer or too can help with that.
Good luck to you both.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883408</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883408</id>
	<title>Yeah, I know.</title>
	<author>Anonymous</author>
	<datestamp>1264335660000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>5</modscore>
	<htmltext>These "Highly Trained Morons" are working on killing my wife. She went in for a Hysterectomy and ended up with her ureter sutured or cauterized shut resulting in her kidney backing up and shutting down. Now she has a tube out her back  to keep her kidney alive and in a few weeks they'll go in an cut her ureter above the blockage and reattach it to her bladder. All for the low, low, price of $$$$$$$$$$$$. Meanwhile, the nursing staff and E/R staff have done everything in their power to see how much additional damage they can do. No one has any common sense or care that I can see. I'm fit to be tied!</htmltext>
<tokenext>These " Highly Trained Morons " are working on killing my wife .
She went in for a Hysterectomy and ended up with her ureter sutured or cauterized shut resulting in her kidney backing up and shutting down .
Now she has a tube out her back to keep her kidney alive and in a few weeks they 'll go in an cut her ureter above the blockage and reattach it to her bladder .
All for the low , low , price of $ $ $ $ $ $ $ $ $ $ $ $ .
Meanwhile , the nursing staff and E/R staff have done everything in their power to see how much additional damage they can do .
No one has any common sense or care that I can see .
I 'm fit to be tied !</tokentext>
<sentencetext>These "Highly Trained Morons" are working on killing my wife.
She went in for a Hysterectomy and ended up with her ureter sutured or cauterized shut resulting in her kidney backing up and shutting down.
Now she has a tube out her back  to keep her kidney alive and in a few weeks they'll go in an cut her ureter above the blockage and reattach it to her bladder.
All for the low, low, price of $$$$$$$$$$$$.
Meanwhile, the nursing staff and E/R staff have done everything in their power to see how much additional damage they can do.
No one has any common sense or care that I can see.
I'm fit to be tied!</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882938</id>
	<title>Never share someone else's radiation</title>
	<author>Anonymous</author>
	<datestamp>1264332300000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>You may be tempted to share someone else's radiation to catch a buzz or light one up or ride the blue dragon as you kids say. But if you read the bottle, you will see: "Federal law prohibits the transfer of this radiation to any person other than the patient for whom it was prescribed." Let this article be a warning to those looking for a cheap high or quickie chemo: Radiation Kills!</p></htmltext>
<tokenext>You may be tempted to share someone else 's radiation to catch a buzz or light one up or ride the blue dragon as you kids say .
But if you read the bottle , you will see : " Federal law prohibits the transfer of this radiation to any person other than the patient for whom it was prescribed .
" Let this article be a warning to those looking for a cheap high or quickie chemo : Radiation Kills !</tokentext>
<sentencetext>You may be tempted to share someone else's radiation to catch a buzz or light one up or ride the blue dragon as you kids say.
But if you read the bottle, you will see: "Federal law prohibits the transfer of this radiation to any person other than the patient for whom it was prescribed.
" Let this article be a warning to those looking for a cheap high or quickie chemo: Radiation Kills!</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884990</id>
	<title>(semi-trolling)</title>
	<author>Anonymous</author>
	<datestamp>1264346280000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>ack... I know I shouldn't be doing this but : &ldquo;Prayer is stronger than radiation&rdquo;<nobr> <wbr></nobr>... why<nobr> <wbr></nobr>... would<nobr> <wbr></nobr>... anyone<nobr> <wbr></nobr>... say<nobr> <wbr></nobr>... this ?</p><p>Nothing wrong with prayer, I suppose, but I get the sense that sometimes it detaches people form the physical reality of problems and discourages actual attempts at change. If I were dying, I'd probably want people to be working harder to finding general cures for the ailments of our species. Do you think praying is a psychologically necessary part of grieving that is going to happen anyway? I suppose if that were the case then it would be beneficial. I suppose I just don't understand why doing nothing is preferable to seeking physical solutions.</p><p>without this technology the cancer would just kill you slowly anyway, so... maybe the odd horribly painful deadly screw-up is worth it.</p><p>I don't want to die of cancer. I want to die of a self inflicted overdose of very fun drugs at a very old age, or die sacrificing myself in some useful way.</p></htmltext>
<tokenext>ack... I know I should n't be doing this but :    Prayer is stronger than radiation    ... why ... would ... anyone ... say ... this ? Nothing wrong with prayer , I suppose , but I get the sense that sometimes it detaches people form the physical reality of problems and discourages actual attempts at change .
If I were dying , I 'd probably want people to be working harder to finding general cures for the ailments of our species .
Do you think praying is a psychologically necessary part of grieving that is going to happen anyway ?
I suppose if that were the case then it would be beneficial .
I suppose I just do n't understand why doing nothing is preferable to seeking physical solutions.without this technology the cancer would just kill you slowly anyway , so... maybe the odd horribly painful deadly screw-up is worth it.I do n't want to die of cancer .
I want to die of a self inflicted overdose of very fun drugs at a very old age , or die sacrificing myself in some useful way .</tokentext>
<sentencetext>ack... I know I shouldn't be doing this but : “Prayer is stronger than radiation” ... why ... would ... anyone ... say ... this ?Nothing wrong with prayer, I suppose, but I get the sense that sometimes it detaches people form the physical reality of problems and discourages actual attempts at change.
If I were dying, I'd probably want people to be working harder to finding general cures for the ailments of our species.
Do you think praying is a psychologically necessary part of grieving that is going to happen anyway?
I suppose if that were the case then it would be beneficial.
I suppose I just don't understand why doing nothing is preferable to seeking physical solutions.without this technology the cancer would just kill you slowly anyway, so... maybe the odd horribly painful deadly screw-up is worth it.I don't want to die of cancer.
I want to die of a self inflicted overdose of very fun drugs at a very old age, or die sacrificing myself in some useful way.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884930</id>
	<title>Replying to myself...</title>
	<author>gbutler69</author>
	<datestamp>1264345740000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext>...to thank all those who expressed concern. Wasn't intended as a sympathy shopping expedition, but, thank you anyway.</htmltext>
<tokenext>...to thank all those who expressed concern .
Was n't intended as a sympathy shopping expedition , but , thank you anyway .</tokentext>
<sentencetext>...to thank all those who expressed concern.
Wasn't intended as a sympathy shopping expedition, but, thank you anyway.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883408</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30889274</id>
	<title>Re:Yeah, I know.</title>
	<author>Anonymous</author>
	<datestamp>1264432080000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>Agreed.  My mother went in for a procedure that required a stay of a few days, and I don't know how many times I told the doctors, nurses, etc., that she needed her anti-rejection meds rather immediately after the surgery.  They all gave me "ok, sure" looks.  I had to smuggle the meds in, while at the same time her regular doctor (who monitored the transplant for the last 10 years) was calling up the hospital trying to get her meds also.  Fortunately, one of the people working in the hospital pharmacy was a former student of my moms and ended up getting everything she needed properly.  Unless you stay on top of these people, its amazing how poorly you are handled.</p></htmltext>
<tokenext>Agreed .
My mother went in for a procedure that required a stay of a few days , and I do n't know how many times I told the doctors , nurses , etc. , that she needed her anti-rejection meds rather immediately after the surgery .
They all gave me " ok , sure " looks .
I had to smuggle the meds in , while at the same time her regular doctor ( who monitored the transplant for the last 10 years ) was calling up the hospital trying to get her meds also .
Fortunately , one of the people working in the hospital pharmacy was a former student of my moms and ended up getting everything she needed properly .
Unless you stay on top of these people , its amazing how poorly you are handled .</tokentext>
<sentencetext>Agreed.
My mother went in for a procedure that required a stay of a few days, and I don't know how many times I told the doctors, nurses, etc., that she needed her anti-rejection meds rather immediately after the surgery.
They all gave me "ok, sure" looks.
I had to smuggle the meds in, while at the same time her regular doctor (who monitored the transplant for the last 10 years) was calling up the hospital trying to get her meds also.
Fortunately, one of the people working in the hospital pharmacy was a former student of my moms and ended up getting everything she needed properly.
Unless you stay on top of these people, its amazing how poorly you are handled.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884850</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884564</id>
	<title>Reminds me of...</title>
	<author>Anonymous</author>
	<datestamp>1264343520000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>I remember reading in some programming instructional material a story of the <a href="http://en.wikipedia.org/wiki/Therac-25" title="wikipedia.org" rel="nofollow"> Therac-25</a> [wikipedia.org]. A lovely device, killed 2 patients due to software errors. Always know your logic-trees!</p></htmltext>
<tokenext>I remember reading in some programming instructional material a story of the Therac-25 [ wikipedia.org ] .
A lovely device , killed 2 patients due to software errors .
Always know your logic-trees !</tokentext>
<sentencetext>I remember reading in some programming instructional material a story of the  Therac-25 [wikipedia.org].
A lovely device, killed 2 patients due to software errors.
Always know your logic-trees!</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30885652</id>
	<title>Re:most of the problems aren't technical</title>
	<author>Anonymous</author>
	<datestamp>1264351560000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>Hassi, if all healthcare workers are as malicious as you seem to think they are, why on earth would a second operator help anymore than a checklist? After all, wouldn't that operator be just as stoned/drunk/psychopathic as the regular operator?</p><p>Fuzzy's post is in line with what human factors and occupational safety researchers have known for years. An organizational culture that takes safety seriously, employee training, and redundancy in safety procedures go a long way toward preventing mistakes, but human error simply can never be completely mitigated. For some reason, we expect healthcare to be exempt from this fact.</p><p>A better use of the chopping block would be to weed out employees who repeatedly introduce error (after implementing training, procedures, and having a safety-focused org culture). There are many ways of deciding this, but one that comes immediately to mind is a tally system for errors. A small safety violation would be worth one mark, a moderate violation worth two, and severe ones worth three (these would have to be defined). Note that violations would be recorded even if no one was actually hurt by the violation, and any mark would require a meeting with a supervisor. When an employee gets three marks, safety retraining that the worker's expense would be required. Five would require demotion or a decrease in pay, and six would result in automatic termination. This allows otherwise good employees who make occasional mistakes to stay with the organization, but also gets rid of careless employees fairly quickly. It also does not prevent a patient from seeking compensation for negligent care. Perfection, no. However, if all healthcare workers made only a handful of safety errors every year, we'd still see a lot of improvement.</p></htmltext>
<tokenext>Hassi , if all healthcare workers are as malicious as you seem to think they are , why on earth would a second operator help anymore than a checklist ?
After all , would n't that operator be just as stoned/drunk/psychopathic as the regular operator ? Fuzzy 's post is in line with what human factors and occupational safety researchers have known for years .
An organizational culture that takes safety seriously , employee training , and redundancy in safety procedures go a long way toward preventing mistakes , but human error simply can never be completely mitigated .
For some reason , we expect healthcare to be exempt from this fact.A better use of the chopping block would be to weed out employees who repeatedly introduce error ( after implementing training , procedures , and having a safety-focused org culture ) .
There are many ways of deciding this , but one that comes immediately to mind is a tally system for errors .
A small safety violation would be worth one mark , a moderate violation worth two , and severe ones worth three ( these would have to be defined ) .
Note that violations would be recorded even if no one was actually hurt by the violation , and any mark would require a meeting with a supervisor .
When an employee gets three marks , safety retraining that the worker 's expense would be required .
Five would require demotion or a decrease in pay , and six would result in automatic termination .
This allows otherwise good employees who make occasional mistakes to stay with the organization , but also gets rid of careless employees fairly quickly .
It also does not prevent a patient from seeking compensation for negligent care .
Perfection , no .
However , if all healthcare workers made only a handful of safety errors every year , we 'd still see a lot of improvement .</tokentext>
<sentencetext>Hassi, if all healthcare workers are as malicious as you seem to think they are, why on earth would a second operator help anymore than a checklist?
After all, wouldn't that operator be just as stoned/drunk/psychopathic as the regular operator?Fuzzy's post is in line with what human factors and occupational safety researchers have known for years.
An organizational culture that takes safety seriously, employee training, and redundancy in safety procedures go a long way toward preventing mistakes, but human error simply can never be completely mitigated.
For some reason, we expect healthcare to be exempt from this fact.A better use of the chopping block would be to weed out employees who repeatedly introduce error (after implementing training, procedures, and having a safety-focused org culture).
There are many ways of deciding this, but one that comes immediately to mind is a tally system for errors.
A small safety violation would be worth one mark, a moderate violation worth two, and severe ones worth three (these would have to be defined).
Note that violations would be recorded even if no one was actually hurt by the violation, and any mark would require a meeting with a supervisor.
When an employee gets three marks, safety retraining that the worker's expense would be required.
Five would require demotion or a decrease in pay, and six would result in automatic termination.
This allows otherwise good employees who make occasional mistakes to stay with the organization, but also gets rid of careless employees fairly quickly.
It also does not prevent a patient from seeking compensation for negligent care.
Perfection, no.
However, if all healthcare workers made only a handful of safety errors every year, we'd still see a lot of improvement.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884160</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883032</id>
	<title>Re:Not a new problem</title>
	<author>twiddlingbits</author>
	<datestamp>1264333020000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext>Human error happens in programming and in medical procedures. It cannot be 100\% eliminated until robots are programming robots. There can be addtional efforts taken to produce quality software such as more testing, more software/hardware interlocks,  formal methods to prove systems, etc.<nobr> <wbr></nobr>.Better traning and maybe other things like actually evaluating the techs and MDs and firing the ones who screw up  more than average could help.

Medical care is under intense pressure to do more with less and thus the techs are rushed or are backed up and overworked thus making mistakes. The software doesn't know this. It does what is asked. So you must correct many issues at the same time, better software, better training, better procedures, more techs, more Radiation Treatment facilities all of which cost more money.  Too much costs and you go out of business, too many mistakes and you do as well. Catch-22.</htmltext>
<tokenext>Human error happens in programming and in medical procedures .
It can not be 100 \ % eliminated until robots are programming robots .
There can be addtional efforts taken to produce quality software such as more testing , more software/hardware interlocks , formal methods to prove systems , etc .
.Better traning and maybe other things like actually evaluating the techs and MDs and firing the ones who screw up more than average could help .
Medical care is under intense pressure to do more with less and thus the techs are rushed or are backed up and overworked thus making mistakes .
The software does n't know this .
It does what is asked .
So you must correct many issues at the same time , better software , better training , better procedures , more techs , more Radiation Treatment facilities all of which cost more money .
Too much costs and you go out of business , too many mistakes and you do as well .
Catch-22 .</tokentext>
<sentencetext>Human error happens in programming and in medical procedures.
It cannot be 100\% eliminated until robots are programming robots.
There can be addtional efforts taken to produce quality software such as more testing, more software/hardware interlocks,  formal methods to prove systems, etc.
.Better traning and maybe other things like actually evaluating the techs and MDs and firing the ones who screw up  more than average could help.
Medical care is under intense pressure to do more with less and thus the techs are rushed or are backed up and overworked thus making mistakes.
The software doesn't know this.
It does what is asked.
So you must correct many issues at the same time, better software, better training, better procedures, more techs, more Radiation Treatment facilities all of which cost more money.
Too much costs and you go out of business, too many mistakes and you do as well.
Catch-22.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882802</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884734</id>
	<title>Re:most of the problems aren't technical</title>
	<author>fuzzyfuzzyfungus</author>
	<datestamp>1264344660000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext>The reason that I don't think that cracking down on the individual who happens to make the error(again, unless they are clearly negligent or malicious about it) will be of much use is the example of occupational safety.<br> <br>

Among industrial workers who deal with big, self-evidently dangerous, machinery(watching an industrial punch or something forming steel should make inferring what it'll do to your hand trivial for even the thickest among us), humans still err from time to time. Even when the penalty is instant gruesome mangling, or death, people still fuck up. This is why properly designed equipment has, wherever possible, design features that make it hard to do serious damage with a small mistake.<br> <br>

You do want to emphasize, and take no shit about, your safety protocol. If checklists are empirically proven to reduce errors, and some hotshot is just too perfect for boring old checklists, he gets told that he can either shape up, or be too cool for checklists somewhere else, assuming he can get hired with the nasty recommendation you'd give him. Absolutely. If you have a well designed protocol in place, failure to adhere to it is negligence, even if nothing bad happens that time, and you don't want negligent people around(the flip side of this, of course, is that whoever designs the protocol and systems has a duty to make sure that they actually work. If your system of safeguards is so onerous that workers have to bypass it to get things done, they will, and then management will have to look the other way, since they also need things to get done, and the system will fail).</htmltext>
<tokenext>The reason that I do n't think that cracking down on the individual who happens to make the error ( again , unless they are clearly negligent or malicious about it ) will be of much use is the example of occupational safety .
Among industrial workers who deal with big , self-evidently dangerous , machinery ( watching an industrial punch or something forming steel should make inferring what it 'll do to your hand trivial for even the thickest among us ) , humans still err from time to time .
Even when the penalty is instant gruesome mangling , or death , people still fuck up .
This is why properly designed equipment has , wherever possible , design features that make it hard to do serious damage with a small mistake .
You do want to emphasize , and take no shit about , your safety protocol .
If checklists are empirically proven to reduce errors , and some hotshot is just too perfect for boring old checklists , he gets told that he can either shape up , or be too cool for checklists somewhere else , assuming he can get hired with the nasty recommendation you 'd give him .
Absolutely. If you have a well designed protocol in place , failure to adhere to it is negligence , even if nothing bad happens that time , and you do n't want negligent people around ( the flip side of this , of course , is that whoever designs the protocol and systems has a duty to make sure that they actually work .
If your system of safeguards is so onerous that workers have to bypass it to get things done , they will , and then management will have to look the other way , since they also need things to get done , and the system will fail ) .</tokentext>
<sentencetext>The reason that I don't think that cracking down on the individual who happens to make the error(again, unless they are clearly negligent or malicious about it) will be of much use is the example of occupational safety.
Among industrial workers who deal with big, self-evidently dangerous, machinery(watching an industrial punch or something forming steel should make inferring what it'll do to your hand trivial for even the thickest among us), humans still err from time to time.
Even when the penalty is instant gruesome mangling, or death, people still fuck up.
This is why properly designed equipment has, wherever possible, design features that make it hard to do serious damage with a small mistake.
You do want to emphasize, and take no shit about, your safety protocol.
If checklists are empirically proven to reduce errors, and some hotshot is just too perfect for boring old checklists, he gets told that he can either shape up, or be too cool for checklists somewhere else, assuming he can get hired with the nasty recommendation you'd give him.
Absolutely. If you have a well designed protocol in place, failure to adhere to it is negligence, even if nothing bad happens that time, and you don't want negligent people around(the flip side of this, of course, is that whoever designs the protocol and systems has a duty to make sure that they actually work.
If your system of safeguards is so onerous that workers have to bypass it to get things done, they will, and then management will have to look the other way, since they also need things to get done, and the system will fail).</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884160</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</id>
	<title>highly trained morons</title>
	<author>timmarhy</author>
	<datestamp>1264330980000</datestamp>
	<modclass>Informativ</modclass>
	<modscore>5</modscore>
	<htmltext>year ago i worked in a pathology lab, and i can atest to the fact the medical field is populated with a lot of highly trained morons. many times the application of these treatments aren't done by someone with enough brain power to understand whats actually happened.</htmltext>
<tokenext>year ago i worked in a pathology lab , and i can atest to the fact the medical field is populated with a lot of highly trained morons .
many times the application of these treatments are n't done by someone with enough brain power to understand whats actually happened .</tokentext>
<sentencetext>year ago i worked in a pathology lab, and i can atest to the fact the medical field is populated with a lot of highly trained morons.
many times the application of these treatments aren't done by someone with enough brain power to understand whats actually happened.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30886032</id>
	<title>Radiotherapy is usually done right</title>
	<author>Anonymous</author>
	<datestamp>1264355040000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>There is painstaking care involved in radiation therapy (at any decent hospital or medical center).  Linear accelerators have many safety interlocks.  They go through a specific QA protocol daily, weekly, monthly and yearly at the hands of a qualified medical physicist.  Gross failures that injure patients are extremely rare, but they inevitably become famous making people suspicious of the field as a whole. Regarding smaller errors and setup uncertainty, the total dose is fractionated - spread out over many days- to prevent any one small error from having a dominant effect.  Thousands of people receive radiotherapy with a positive outcome or, at least, without any problems associated with the delivery of therapy.</p></htmltext>
<tokenext>There is painstaking care involved in radiation therapy ( at any decent hospital or medical center ) .
Linear accelerators have many safety interlocks .
They go through a specific QA protocol daily , weekly , monthly and yearly at the hands of a qualified medical physicist .
Gross failures that injure patients are extremely rare , but they inevitably become famous making people suspicious of the field as a whole .
Regarding smaller errors and setup uncertainty , the total dose is fractionated - spread out over many days- to prevent any one small error from having a dominant effect .
Thousands of people receive radiotherapy with a positive outcome or , at least , without any problems associated with the delivery of therapy .</tokentext>
<sentencetext>There is painstaking care involved in radiation therapy (at any decent hospital or medical center).
Linear accelerators have many safety interlocks.
They go through a specific QA protocol daily, weekly, monthly and yearly at the hands of a qualified medical physicist.
Gross failures that injure patients are extremely rare, but they inevitably become famous making people suspicious of the field as a whole.
Regarding smaller errors and setup uncertainty, the total dose is fractionated - spread out over many days- to prevent any one small error from having a dominant effect.
Thousands of people receive radiotherapy with a positive outcome or, at least, without any problems associated with the delivery of therapy.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882802</id>
	<title>Not a new problem</title>
	<author>Anonymous</author>
	<datestamp>1264331460000</datestamp>
	<modclass>Informativ</modclass>
	<modscore>5</modscore>
	<htmltext>Bad software combined with poor training is not a new problem. In fact, one of the most famous serious failures of medical radiation technology. The most famous example is the Therac-25 debacle in the 1980s <a href="http://en.wikipedia.org/wiki/Therac-25" title="wikipedia.org">http://en.wikipedia.org/wiki/Therac-25</a> [wikipedia.org] which caused multiple deaths. In that case, a combination of bad software design (leading to race conditions), bad hardware interfaces and training issues combined to create a perfect storm of bad conditions. This appears in textbooks. Problems like this shouldn't still be happening.</htmltext>
<tokenext>Bad software combined with poor training is not a new problem .
In fact , one of the most famous serious failures of medical radiation technology .
The most famous example is the Therac-25 debacle in the 1980s http : //en.wikipedia.org/wiki/Therac-25 [ wikipedia.org ] which caused multiple deaths .
In that case , a combination of bad software design ( leading to race conditions ) , bad hardware interfaces and training issues combined to create a perfect storm of bad conditions .
This appears in textbooks .
Problems like this should n't still be happening .</tokentext>
<sentencetext>Bad software combined with poor training is not a new problem.
In fact, one of the most famous serious failures of medical radiation technology.
The most famous example is the Therac-25 debacle in the 1980s http://en.wikipedia.org/wiki/Therac-25 [wikipedia.org] which caused multiple deaths.
In that case, a combination of bad software design (leading to race conditions), bad hardware interfaces and training issues combined to create a perfect storm of bad conditions.
This appears in textbooks.
Problems like this shouldn't still be happening.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30886998</id>
	<title>Look at it this way</title>
	<author>WinstonWolfIT</author>
	<datestamp>1264451280000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext>Sometimes a dumb mistake can be dumb luck. For instance, if the best diagnostician in the country misdiagnoses a patient and orders radiation which would then wipe out his immune system and leave him doomed to the infection that is really his underlying problem, dosing the wrong patient might work out in the end.

It could happen.</htmltext>
<tokenext>Sometimes a dumb mistake can be dumb luck .
For instance , if the best diagnostician in the country misdiagnoses a patient and orders radiation which would then wipe out his immune system and leave him doomed to the infection that is really his underlying problem , dosing the wrong patient might work out in the end .
It could happen .</tokentext>
<sentencetext>Sometimes a dumb mistake can be dumb luck.
For instance, if the best diagnostician in the country misdiagnoses a patient and orders radiation which would then wipe out his immune system and leave him doomed to the infection that is really his underlying problem, dosing the wrong patient might work out in the end.
It could happen.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30884608</id>
	<title>hollywood upstairs medical college</title>
	<author>Joe The Dragon</author>
	<datestamp>1264343820000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>Hollywood upstairs medical college is like that and the dockets where wow dates by getting them any (drug) that they want.</p></htmltext>
<tokenext>Hollywood upstairs medical college is like that and the dockets where wow dates by getting them any ( drug ) that they want .</tokentext>
<sentencetext>Hollywood upstairs medical college is like that and the dockets where wow dates by getting them any (drug) that they want.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883034</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883610</id>
	<title>Re:Not a new problem</title>
	<author>RDW</author>
	<datestamp>1264336740000</datestamp>
	<modclass>Informativ</modclass>
	<modscore>2</modscore>
	<htmltext><p>The NYT article mentions Varian treatment planning software. Looking at a recent safety warning:</p><p><a href="http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/FieldSafetyNoticesformedicaldevices/CON068203" title="mhra.gov.uk">http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/FieldSafetyNoticesformedicaldevices/CON068203</a> [mhra.gov.uk]</p><p>it seems that, as in the case of the Therac-25, an unexpected sequence of user inputs (in this case 'removing the Primary Reference Point...prior to performing planning approval') can under certain circumstances cause an error ('the resulting calculated dose may differ significantly from the original plan'), and that no appropriate error message is generated ('There is no warning message presented during the approval stage indicating that the Primary Reference Point is missing.'). This may well be completely unrelated to the NYT incidents, but it's interesting (though perhaps not surprising) that behaviour of this type can still occur in safety-critical applications.</p></htmltext>
<tokenext>The NYT article mentions Varian treatment planning software .
Looking at a recent safety warning : http : //www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/FieldSafetyNoticesformedicaldevices/CON068203 [ mhra.gov.uk ] it seems that , as in the case of the Therac-25 , an unexpected sequence of user inputs ( in this case 'removing the Primary Reference Point...prior to performing planning approval ' ) can under certain circumstances cause an error ( 'the resulting calculated dose may differ significantly from the original plan ' ) , and that no appropriate error message is generated ( 'There is no warning message presented during the approval stage indicating that the Primary Reference Point is missing. ' ) .
This may well be completely unrelated to the NYT incidents , but it 's interesting ( though perhaps not surprising ) that behaviour of this type can still occur in safety-critical applications .</tokentext>
<sentencetext>The NYT article mentions Varian treatment planning software.
Looking at a recent safety warning:http://www.mhra.gov.uk/Safetyinformation/Safetywarningsalertsandrecalls/FieldSafetyNoticesformedicaldevices/CON068203 [mhra.gov.uk]it seems that, as in the case of the Therac-25, an unexpected sequence of user inputs (in this case 'removing the Primary Reference Point...prior to performing planning approval') can under certain circumstances cause an error ('the resulting calculated dose may differ significantly from the original plan'), and that no appropriate error message is generated ('There is no warning message presented during the approval stage indicating that the Primary Reference Point is missing.').
This may well be completely unrelated to the NYT incidents, but it's interesting (though perhaps not surprising) that behaviour of this type can still occur in safety-critical applications.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882802</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883020</id>
	<title>Re:highly trained morons</title>
	<author>Anonymous</author>
	<datestamp>1264332900000</datestamp>
	<modclass>Interestin</modclass>
	<modscore>3</modscore>
	<htmltext><p>Indeed, most of these errors don't sound like Therac-25 type errors, more like PEBKAC errors.</p><p>These can only be solved by double checking(more labor costs? not likely) or by patients who care enough about themselves to take a black marker and write "radiation goes here, dumbass".</p><p>I've done similar things ever since I went in for an operation where they started the incision on the wrong side then decided they'd just go with it and tunnel across my abdomen instead of starting over in the right spot.</p></htmltext>
<tokenext>Indeed , most of these errors do n't sound like Therac-25 type errors , more like PEBKAC errors.These can only be solved by double checking ( more labor costs ?
not likely ) or by patients who care enough about themselves to take a black marker and write " radiation goes here , dumbass " .I 've done similar things ever since I went in for an operation where they started the incision on the wrong side then decided they 'd just go with it and tunnel across my abdomen instead of starting over in the right spot .</tokentext>
<sentencetext>Indeed, most of these errors don't sound like Therac-25 type errors, more like PEBKAC errors.These can only be solved by double checking(more labor costs?
not likely) or by patients who care enough about themselves to take a black marker and write "radiation goes here, dumbass".I've done similar things ever since I went in for an operation where they started the incision on the wrong side then decided they'd just go with it and tunnel across my abdomen instead of starting over in the right spot.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883066</id>
	<title>Re:highly trained morons</title>
	<author>Anonymous</author>
	<datestamp>1264333380000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>You mean that in America people are treated by carrots* in lab coats?!?<br>No wonder so many mistakes are made in your hospitals!!</p><p>*stick that in an English-Welsh translator and you shall see what I mean.</p><p>With love,<br>The Anonymous Coward</p></htmltext>
<tokenext>You mean that in America people are treated by carrots * in lab coats ? !
? No wonder so many mistakes are made in your hospitals ! !
* stick that in an English-Welsh translator and you shall see what I mean.With love,The Anonymous Coward</tokentext>
<sentencetext>You mean that in America people are treated by carrots* in lab coats?!
?No wonder so many mistakes are made in your hospitals!!
*stick that in an English-Welsh translator and you shall see what I mean.With love,The Anonymous Coward</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882740</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882842</id>
	<title>More harrowing stories...</title>
	<author>pongo000</author>
	<datestamp>1264331700000</datestamp>
	<modclass>None</modclass>
	<modscore>1</modscore>
	<htmltext><p>...such as the <a href="http://en.wikipedia.org/wiki/Therac-25" title="wikipedia.org">Therac-25 malfunction</a> [wikipedia.org] that is the textbook case of how poorly-designed UIs can have catastrophic repercussions. The <a href="http://sunnyday.mit.edu/papers/therac.pdf" title="mit.edu">Nancy Leveson article</a> [mit.edu] cited is a fascinating read.  It is required reading for my advanced computer science students.</p></htmltext>
<tokenext>...such as the Therac-25 malfunction [ wikipedia.org ] that is the textbook case of how poorly-designed UIs can have catastrophic repercussions .
The Nancy Leveson article [ mit.edu ] cited is a fascinating read .
It is required reading for my advanced computer science students .</tokentext>
<sentencetext>...such as the Therac-25 malfunction [wikipedia.org] that is the textbook case of how poorly-designed UIs can have catastrophic repercussions.
The Nancy Leveson article [mit.edu] cited is a fascinating read.
It is required reading for my advanced computer science students.</sentencetext>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30886848</id>
	<title>Re:highly trained morons</title>
	<author>Anonymous</author>
	<datestamp>1264449600000</datestamp>
	<modclass>Insightful</modclass>
	<modscore>2</modscore>
	<htmltext><p>"Indeed, most of these errors don't sound like Therac-25 type errors, more like PEBKAC errors."</p><p>Actually, a lot of these sound like Therac-25 type errors - not to mention that mission-critical software that can cause harm when used incorrectly should be designed in a way that recognizes PEBKAC errors exist.</p><p>The article talks about the Varian software a little.  For one of the machines, the procedure appears to be:<br>1.  set treatment parameters, click "save"<br>2.  set the part of the body to scan, click "save"<br>3.  set some other parameters, click "save" to finalize the plan</p><p>The operator did 1), and finished 2) but the program crashed when she hit "save".  She then restarted the program and did 3), thinking that it in fact saved part 2) (but it didn't).  From a software point of view:<br>1.  the program shouldn't crash.  It certainly shouldn't crash with the frequency observed (it crashed two or three more times during the treatment involved in this article).<br>2.  the program should never have let treatment proceed without getting proper answers for part 2).<br>3.  the software design should do all within its power to validate a treatment before allowing use on a patient.  It could involve running simulations (eg. with all the requested parameters, is any body part exposed beyond safe limits?), or it could involve a physical test (the article says that it was common practice to do a test run first, but not required - it was skipped due to understaffing).  Require the test, and \_don't\_ proceed until the operator does it.</p><p>All three of these are exactly Therac-25 problems (eg. program crashed due to a buggy key input routine, allowed the operator to proceed to the next screen without setting values, and neglected to double-check parameters for safety).</p><p>Fewer PEBKAC errors would have helped them catch the error before it became a problem, sure.  But a design that doesn't take all reasonable precautions to eliminate human error - or, worse, that counts on the user to fix software errors - is flawed.</p><p>I am also astounded by the poor follow-up.  The guy's wife complains to his doctors that something is wrong, and (instead of suspending therapy) they have her talk to a psychiatrist and give him another session of the botched radiation exposure.  You could describe this as PEBKAC, but I'd say it's really a matter of procedure ("human" software).  Sometimes, things just go wrong even though everyone did the right thing.  But, based on the article, this really isn't one of those cases.</p></htmltext>
<tokenext>" Indeed , most of these errors do n't sound like Therac-25 type errors , more like PEBKAC errors .
" Actually , a lot of these sound like Therac-25 type errors - not to mention that mission-critical software that can cause harm when used incorrectly should be designed in a way that recognizes PEBKAC errors exist.The article talks about the Varian software a little .
For one of the machines , the procedure appears to be : 1. set treatment parameters , click " save " 2. set the part of the body to scan , click " save " 3. set some other parameters , click " save " to finalize the planThe operator did 1 ) , and finished 2 ) but the program crashed when she hit " save " .
She then restarted the program and did 3 ) , thinking that it in fact saved part 2 ) ( but it did n't ) .
From a software point of view : 1. the program should n't crash .
It certainly should n't crash with the frequency observed ( it crashed two or three more times during the treatment involved in this article ) .2. the program should never have let treatment proceed without getting proper answers for part 2 ) .3. the software design should do all within its power to validate a treatment before allowing use on a patient .
It could involve running simulations ( eg .
with all the requested parameters , is any body part exposed beyond safe limits ?
) , or it could involve a physical test ( the article says that it was common practice to do a test run first , but not required - it was skipped due to understaffing ) .
Require the test , and \ _do n't \ _ proceed until the operator does it.All three of these are exactly Therac-25 problems ( eg .
program crashed due to a buggy key input routine , allowed the operator to proceed to the next screen without setting values , and neglected to double-check parameters for safety ) .Fewer PEBKAC errors would have helped them catch the error before it became a problem , sure .
But a design that does n't take all reasonable precautions to eliminate human error - or , worse , that counts on the user to fix software errors - is flawed.I am also astounded by the poor follow-up .
The guy 's wife complains to his doctors that something is wrong , and ( instead of suspending therapy ) they have her talk to a psychiatrist and give him another session of the botched radiation exposure .
You could describe this as PEBKAC , but I 'd say it 's really a matter of procedure ( " human " software ) .
Sometimes , things just go wrong even though everyone did the right thing .
But , based on the article , this really is n't one of those cases .</tokentext>
<sentencetext>"Indeed, most of these errors don't sound like Therac-25 type errors, more like PEBKAC errors.
"Actually, a lot of these sound like Therac-25 type errors - not to mention that mission-critical software that can cause harm when used incorrectly should be designed in a way that recognizes PEBKAC errors exist.The article talks about the Varian software a little.
For one of the machines, the procedure appears to be:1.  set treatment parameters, click "save"2.  set the part of the body to scan, click "save"3.  set some other parameters, click "save" to finalize the planThe operator did 1), and finished 2) but the program crashed when she hit "save".
She then restarted the program and did 3), thinking that it in fact saved part 2) (but it didn't).
From a software point of view:1.  the program shouldn't crash.
It certainly shouldn't crash with the frequency observed (it crashed two or three more times during the treatment involved in this article).2.  the program should never have let treatment proceed without getting proper answers for part 2).3.  the software design should do all within its power to validate a treatment before allowing use on a patient.
It could involve running simulations (eg.
with all the requested parameters, is any body part exposed beyond safe limits?
), or it could involve a physical test (the article says that it was common practice to do a test run first, but not required - it was skipped due to understaffing).
Require the test, and \_don't\_ proceed until the operator does it.All three of these are exactly Therac-25 problems (eg.
program crashed due to a buggy key input routine, allowed the operator to proceed to the next screen without setting values, and neglected to double-check parameters for safety).Fewer PEBKAC errors would have helped them catch the error before it became a problem, sure.
But a design that doesn't take all reasonable precautions to eliminate human error - or, worse, that counts on the user to fix software errors - is flawed.I am also astounded by the poor follow-up.
The guy's wife complains to his doctors that something is wrong, and (instead of suspending therapy) they have her talk to a psychiatrist and give him another session of the botched radiation exposure.
You could describe this as PEBKAC, but I'd say it's really a matter of procedure ("human" software).
Sometimes, things just go wrong even though everyone did the right thing.
But, based on the article, this really isn't one of those cases.</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883020</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30885444</id>
	<title>Re:Breaking news</title>
	<author>Anonymous</author>
	<datestamp>1264350000000</datestamp>
	<modclass>None</modclass>
	<modscore>0</modscore>
	<htmltext><p>You mean like a car?</p></htmltext>
<tokenext>You mean like a car ?</tokentext>
<sentencetext>You mean like a car?</sentencetext>
	<parent>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30883822</parent>
</comment>
<comment>
	<id>http://www.semanticweb.org/ontologies/ConversationInstances.owl#comment10_01_24_201205.30882824</id>
	<title>Therac-25</title>
	<author>slimjim8094</author>
	<datestamp>1264331580000</datestamp>
	<modclass>Informativ</modclass>
	<modscore>4</modscore>
	<htmltext><p><a href="http://en.wikipedia.org/wiki/Therac-25" title="wikipedia.org">http://en.wikipedia.org/wiki/Therac-25</a> [wikipedia.org]</p><p>Famously killed 2 people as a result of radiation poisoning. It's also a case study in software design - the software was reused on a model without hardware interlocks; this allowed the machine to get into an inconsistent state where it would deliver something like a hundred times the intended dose.</p><p>You'd think people would've learned.</p></htmltext>
<tokenext>http : //en.wikipedia.org/wiki/Therac-25 [ wikipedia.org ] Famously killed 2 people as a result of radiation poisoning .
It 's also a case study in software design - the software was reused on a model without hardware interlocks ; this allowed the machine to get into an inconsistent state where it would deliver something like a hundred times the intended dose.You 'd think people would 've learned .</tokentext>
<sentencetext>http://en.wikipedia.org/wiki/Therac-25 [wikipedia.org]Famously killed 2 people as a result of radiation poisoning.
It's also a case study in software design - the software was reused on a model without hardware interlocks; this allowed the machine to get into an inconsistent state where it would deliver something like a hundred times the intended dose.You'd think people would've learned.</sentencetext>
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