Field of Science

When radiation misfires...literally

The New York Times has a rather chilling account of how radiation overdose in the treatment of some cancer patients caused deadly side effects leading to death. The entire sobering article deserves to be read. In one case a man's tongue was going to be selectively irradiated; instead his whole face received a blast of radiation that led to a horrible, slow death. Scott Jerome-Parks's story makes for very painful reading. In another case, misguided radiation beams literally cut out a hole in a woman's chest that gradually killed her. This was Alexandra Jn-Charles. Both Mr. Jerome Parks and Ms. Jn Charles died within a month of each other in 2007.

And all this mainly because of computer errors that were not detected by human beings, errors that caused the radiation to be overdosed or misdirected. Seems like one of those classic "technology is a double-edged sword" kind of scenarios with the whole system just becoming too complex for human understanding. In one instance, a wedge in a linear accelerator delivering the radiation was supposed to focus the beam in the "in" position. But the computer that used Varian software- the same software that I used in grad school for operating the NMR spectrometer built by the same company- made a mistake and instead pivoted the wedge to the "out" position, removing the radiation shielding. The mistake was not detected 27 times, leading to acute radiation overdoses in the wrong parts of the body. In the case of the man whose tongue was supposed to be treated, an error in the software failed to save the critical settings for the accelerator which would have focused the radiation to the right parts. The computer repeatedly crashed, leading to the collimator beams being left wide open, and nobody noticed this.

The statistics unearthed by the Times are startling. From 2001 to 2009, more than 600 cases of improper radiation treatment were reported. Out of those, 255 were related to an overdose, while 284 were related to the wrong parts of the body being exposed to radiation. Even in its idealized form radiation has side-effects, so one would assume that doctors and technicians would be deathly serious about operating these protocols. These statistics were collected for New York State, which is apparently supposed to have some of the strictest radiation standards in the country.

What is even more shocking is the lack of transparency due to "privacy laws". Names of the culprits have been withheld, and some of them seem to have been let off the hook with a simple reprimand. St. Vincent's hospital and University Hospital of Brooklyn, where the two accidents had happened, were simply fined a thousand dollars by the city of New York. Some doctors who have participated in the treatments refused to talk to the journalists. There also does not seem to be a single agency responsible for these radiation safeguards. On top of it all there seem to be scant ways for patients to pick beforehand which hospital they would like to receive radiation treatment in, since records of mistakes are not available to the public. The whole shebang sounds appalling.

Now I understand that 600 cases in 8 years is probably small potatoes compared to the total number of cases in which radiation has worked successfully. Nonetheless, the factors responsible for the lapses and the horrendous consequences deserve scrutiny (seriously, death due to "computer error" sounds like something out of a bad science fiction horror movie). For something as serious as radiation treatment for cancer, one would assume that the same kinds of safeguards, fail-safe mechanisms and backup checks would be in place as are used in nuclear reactor safety. What boggles my mind is that there exist no fail safe mechanisms which would simply shut down the system when they detect an overdose. It simply seems that shoddy training, computer error, and lack of accountability are dealing out death and enormous physical and psychological suffering to patients and their families.


  1. It is an interesting contrast with this BBC News article, also written this weekend.

  2. Sounds very different indeed. Maybe it's time for these guys to take a hard look at state laws.

  3. The worst part is that it would seem accountability is simply impossible without fines, penalties, and the expense of regulation. Time and time again we get more evidence that we simply can't trust the people administering treatment to be accountable without the proverbial sword of Damocles hanging over them. Yet their is a constant cry to limit the liability of medical professionals.

  4. True. I always thought that libertarian arguments arguing for no regulation overlooked an important parameter- human nature

  5. Perhaps I'm mistaken but Varian Medical might be different than Varian Scientific. I can't find any link between their websites ( and, respectively), and they even trade under different stock symbols, VAR and VARI (until Varian Inc is acquired by Aligent, I guess)

    Sorry to be so nit-picky, but I'm glad they're separate companies. I barely trust the Varian software to autoshim correctly, and the UI isn't the user-friendliest. I'd hate to see them try their hand at medical instrumentation...

  6. The resemblance between this and the THERAC-25 accidents (in the eighties!) is extremely chilling.

  7. doees someone knows who were the programmers or at least the departement in Varian Medical systems who designed the linear accelerator's software UI in the Jerome Parks case?


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