Tag Archives: CDC

Quis custodiet ipsos medici?

Internet security is in a position similar to that of safety in the medical industry. Many doctors have an opinion like this one, quoted by Kent Bottles:
“Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. A measly 26% have blood pressure at goal. All my grades are well below my institution’s targets.” And she says, “I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations.”

Meanwhile, according to the CDC, 99,000 people die in the U.S. per year because of health-care associated infections. That is equivalent of an airliner crash every day. It’s three times the rate of deaths by automobile accidents.

The basic medical error problems observed by Dennis Quaid when his twin babies almost died due to repeated massive medically-administered overdoses and due to software problems such as ably analysed by Nancy Leveson for the infamous 1980s Therac-25 cancer-radiation device are not in any way unique to computing in medicine. The solutions to those problems are analogous to some of the solutions IT security needs: measurements plus six or seven layers of aggregation, analysis, and distribution.

As Gardiner Harris reported in the New York Times, August 20, 2010, another problem is that intravenous and feeding tubes are not distinguished by shape or color: Continue reading →

What we can learn from the Therac-25

What does Nancy Leveson’s classic analysis of the Therac-25 recommend? (“An Investigation of the Therac-25 Accidents,” by Nancy Leveson, University of Washington and Clark S. Turner, University of California, Irvine, IEEE Computer, Vol. 26, No. 7, July 1993, pp. 18-41.)
“Inadequate Investigation or Followup on Accident Reports. Every company building safety-critical systems should have audit trails and analysis procedures that are applied whenever any hint of a problem is found that might lead to an accident.” p. 47

“Government Oversight and Standards. Once the FDA got involved in the Therac-25, their response was impressive, especially considering how little experience they had with similar problems in computer-controlled medical devices. Since the Therac-25 events, the FDA has moved to improve the reporting system and to augment their procedures and guidelines to include software. The input and pressure from the user group was also important in getting the machine fixed and provides an important lesson to users in other industries.” pp. 48-49

The lesson being that you have to have built-in audit, reporting, transparency, and user visibility for reputation.

Which is exactly what Dennis Quaid is asking for.

Remember, most of those 99,000 deaths a year from medical errors aren’t due to control of complicated therapy equipment: Continue reading →

Dennis Quaid: Medical negligence deaths as many as a major airline crash every day

People think Internet security is bad (it is), but let’s look at medical security:
“Actor Dennis Quaid has become an advocate for electronic medical records. In 2007 his 12 day old twins received a massive accidental overdose (10,000 units of heparin instead of 10 units), a near-fatal error that could have been prevented by the kind of bar code technology that the VA has been using for decades. (Yes, folks, sorry, a government institution was decades ahead of privatized healthcare on this.)”

“Quaid points out that the widely quote 100,000 accidental deaths every year from medical errors equates to a major airline crash every day.”

I point out that that’s three times the annual deaths from automobiles, and around #5 in leading causes of death in the U.S.

-jsq

Crossing the Street in Cyberspace: Michael Kaiser and the National Cyber Security Alliance

If you grew up in a small town, you’d likely cross the street without stopping to look each way. Try that in New York City, and you’ll end up in the hospital. Similarly, most of us grew up in meatspace and clicking on any old link in cyberspace often ends up with our bank account in the hospital.

OK, that was my mangled simile, but it illustrates what Michael Kaiser and the National Security Alliance are trying to do: educate the public about what to do and not do in cyberspace without losing their audience with technical details or lengthy pedantic instructions. In his talk at APWG he had all sorts of interesting points, such as address different audiences (K-12, small business, elderly, etc.) differently, and that it’s not just unlearning bad habits (including ones that would be good habits in other contexts), it’s teaching good habits. ANd changing habits of any kind requires repetition and persistence. As Kaiser said, look at the CDC and its ongoing campaigns of prevention of HIV, domestic violence, etc.

Personally, I think staysafeonline.org could use more graphics and less text, or, more importantly, more storyline. It seems a tad pedantic to me. More poets in prevention! Or more marketing in staying safe. Or something.

But it’s a useful site already.