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Therac-25 Dilemma - Coggle Diagram
Therac-25 Dilemma
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Relevant Facts
Yakima Valley Memorial Hospital, Yakima Washington. A woman treated with Therac-25 developed erythema on her buttocks after one session.
The FDA announced that Therac-25 was defective, and they did not give users enough letters about the "fix". FDA requires AECL to provide CAP.
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Although the software has been modified, the problem still occurs
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What could have been done differently or should be done in the future? done in the future? Done in the future? done in the future?
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Add safety measures, such as adding a device to monitor the radiation dose in real time, and stop the device immediately if it exceeds the limit
On the basis of the original equipment, new equipment or new therapy is developed to replace the existing therapy.
Decision (Option 1)
Prevents more patients from being harmed. Clearly continuing using Therac-25 caused more patients to experience burns and an incorrect dosage of the treatment.
More deaths will be prevented
Give time for the manufacturer to work on the software and CAP.
Policies
- Healthcare facility must have a form of quality control activity done daily on medical equipment.
- Manufacturer of medical equipment must have a trained specialist on-site in every healthcare facility their equipment is being used.
- Software reviewed by internal quality team and external company to assure compliance