Center Treats Wrong Side Of Patient’s Brain
DETROIT — A patient undergoing treatment at the Karmanos Cancer Institute in Detroit received a dose of radiation on the wrong side of the brain, according to a report filed with the United States Nuclear Regulatory Commission.
According to the report, a crucial piece of information was misread prior to treatment with a gamma knife, which delivers a targeted form of radiation therapy that zeros in on specific locations in the brain.
The patient went through a routine MRI (magnetic resonance imaging) scan of the brain just before the procedure, but went into the scanner “feet first,” rather than the standard practice of head first, the document said.
“The gamma knife-authorized medical physicist failed to recognize the scanning error when importing the MRI images into the Gamma Knife treatment planning computer, and subsequently registered them as head first,” the report said. “This resulted in the wrong side of the patient being targeted and treated.”
What went wrong? Deviation from standards (if there are standards)? Too-busy doctors? I’ll be interested to see who gets the blame.
The multiple monitor post made me think of something I read yesterday. This is from The Design of Everyday Things by Don Norman in 1988.
“Would you like a pocket-size device that reminded you of each appointment and daily event? I would. I am waiting for the day when portable computers become small enough that I can keep one with me at all times. I will definitely put all my reminding burdens upon it. It has to be small. It has to be convenient to use. And it has to be relatively powerful, at least by today’s standards. It has to have a full, standard typewriter keyboard and a reasonably large display. It needs good graphics, because that makes a tremendous difference in usability, and a lot of memory – a huge amount, actually. And it should be easy to hook up to the telephone; I need to connect it to my home and laboratory computers. Of course, it should be relatively inexpensive.”
When Norman wrote this, the “first PDA” had been on the market 4 years. Though armed with a full (though alphabetic) keyboard, it hardly fulfilled Norman’s ideals.
Today, of course, even the technologicaly challenged own one of these, only differing in that it IS a phone rather than having to hook it to one:
One thing I find interesting: the device above fits Norman’s functional desires to a T. However, if there is anything that still needs usability improved… it is the cell phone.
And if there is anything that needs it more than a cell phone, it’s anything combined with a cell phone.