January 12, 2010

Reviewing Therac-25 Incidents


            Through the years, the medical community has witnessed a number of innovations that changed the way medical procedures and patient care is being delivered. From the discovery of new and more effective medicines to the invention of equipment that aims to make procedures more accurate and safe, the medical community have been open to changes. One such change that has been in the heart of the practice of medicine is computers.

The use of computers by the medical community is on the rise. Hospitals use computers to store patients' medical records, monitor vital signs, diagnoses and surgery to name a few. This implies that the medical community is becoming dependent upon new technologies with the hopes of making their practice safer and more efficient.

However, computers are also designed by humans, which mean that it is prone to human errors as any other human endeavour. This suggests that the use of modern computer based procedure in the medical field witnessed some accidents that resulted to harm instead of cure of a disease. One of the most noted accidents in the medical field involving computers happened between June 1985 and January 1987. The equipment involved in the said accidents was the Therac-25. In the end, six accidents were reported that resulted to death and serious injuries (Leveson & Turner, 1993).


Background of the Study

            Therac-25 is a linear accelerator that uses high-energy radiation to obliterate cancerous sells without harming nearby healthy cells. The equipment was produced by a Canadian firm known as the Atomic Energy of Canada, Ltd. (AECL) (Thompson, 1987). Installed into the system of Therac-25 is a software that the technician uses to control the mode of the equipment. The software helps the technician to set the length as well as the strength of radiation to be administered to the patient.

            It is essential that the treatment be timed controlled effectively since the treatment being administered also posses potential threats to the patients undergoing treatment. The use of the software on Therac-25 was believed to be the solution to the need for accuracy when using the device. However, the plan backfired. Instead of resulting to efficient and accurate doses being administered to patient, Therac-25 ended up delivering lethal does of radiation to some of its patients.

            One of the incidents involved a woman being treated for cervical cancer at the Hamilton Clinic. The computer failed to stop process of delivering radiation to the patient despite the fact that some of the parts of the machine were not properly placed. This resulted to an overdose. It should have been the case that the computer recognized abnormalities in the positioning of the parts and should have prevented the procedure from taking place.

            After this incident, a couple more mishaps occurred. Because of this, the Therac-25 was deemed as defective under the FDA regulations. The incidents were investigated and a corrective plan was requested to be completed. The corrective plan was essential if the equipment is to be again for cancer treatment. Therac-25 have the potential of helping many cancer patients in surviving the disease. Therefore, the correction of the faults is vital in the advancement of cancer treatment.


Statement of the Problem


            Due to the incidents that resulted to death and serious injuries the Therac-25 was prevented from delivering a potential effective treatment for cancer. The problems that the machine encountered during its use resulted to its removal from the market. In light of this, the topic being proposed aims to answer some questions in the hope of developing a corrective plan that will put the machine into use once again without the fatal side effects. With this, the research must be able to answer the following questions:

  1. What caused the machine to malfunction?
  2. Was the software installed to blame for the deaths and the serious injuries obtained by the patients?
  3. Is there a way to correct the flaws of the machine?


Objectives of the Study


            The study being proposed aims to:

-          Investigate the reasons behind the incidents involving the Therac-25

-          Determine the role that the software played in the malfunction of Therac-25

-          Present a corrective plan to counter the problems that Thereac-25 faced during its use




            In order for the aims of the research to be achieved, the overall methodology that will be used in the research is the systematic review of related literature. Since the machine is no longer in use, the research must depend on the results of previous investigations in order to determine and present the perceived causes of the malfunction.

            The descriptive method will also be used. The descriptive research method where the general part of the paper will be consumed by description of the subject in question. The functions and characteristics will be given importance to illustrate how the practice is being handled.  According to Malthotra, Shaw and Oppenheim (2002), descriptive research method uses characteristics that have been marked before drawing a specific hypothesis.

            The findings of previous studies will help the research to draw its conclusion regarding the ability of the machine to be used for treating cancer and formulating the corrective plan needed to make the procedure more safe and efficient in combating the said disease.



Leveson, N & Turner, C. (1993). An Investigation of the Therac-25 Accidents. IEEE Computer. 26(7), pp.18-41.

Malhotra, N., Hall, J., Shaw, M. & Oppenheim, P. (2002). Marketing Research, (2nd edn). Prentice Hall: Australia.

Thompson, R. (1987). Faulty Therapy Machine causes Radiation Overdoses. FDA Consumer. 21(10), pp. 37+.

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