Safety Regulations Still Written In Blood
We learn by our mistakes, which is part of the price we pay for not being omniscient. The risks of using increasingly complicated software to control powerful equipment could be reduced by some simple fail safe procedures, but getting these in place might take some time.
A recent post at KevinMD, titled Doctors are responsible for a minority of medical mistakes in radiation therapy by Amy Tuteur, MD, showed not only the dangers of radiation treatment, but also the sequence of events by which the dangers are not recognized, resulting in serious injury and, in some cases, death.
Everyone involved with these systems have some responsibility, not least the programmers who code the computer systems and the information architects who design them. Those who use these systems are at the mercy of assumptions made by the designers and developers, often unstated and rarely tested to the limits.
Any one can design and build a complex system that works well when everything goes right. Handling the what-ifs is, ultimately, the differentiator. Having the equipment diagnose itself is not sufficient, a consequence of Godel’s Incompleteness Theorem. Much has been made lately of using simple checklists in medical environments, primarily in the operating theater, but the same can be applied to every process and procedure, particularly with potentially dangerous equipment.
The programmers may be far removed from the chain of responsibility, but they should be mindful of the consequences of their implementations. The same could well be said for those who programmed the fantastically complicated financial systems that led to the recent financial meltdown, and how they either forgot, or worse were not aware of, the lessons of the failure of Long Term Capital Management at the hands of an earlier generation of high powered computer systems, programmed by fallible human assumptions.
In this specific case, changes will be made and procedures modified in light of the experience, as was done when the Challenger’s O-Ring problem was recognized.
© Copyright 2010 Chuck Brooks for FutureWare SCG
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Tags: equipment safety, kevinmd, medical checklists, responsible software design