Scribd
Upload
40 views9 pages

Therac-25 Public Testing

Uploaded by

locle30092004
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
40 views9 pages

Therac-25 Public Testing

Uploaded by

locle30092004
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 9

Borcelle Hospital

Therac-25 public testing


accidental overdose
Members

Lê Xuân Bảo Lộc - IELSIU22057


Hoàng Anh Khôi - IELSIU22049
Vũ Đức Minh - IELSIU22063
Võ Thanh Đức - IELSIU20286
Case Study The Therac-25 could accelerate either
electrons or X-ray photons. Radiation
therapy uses these high-energy
particles to target and kill cancer cells.

“The accidents involving the


Therac-25 date back to the months
between June 1985 and January
1987, comprising at least six known
events of improper dosing of
patients”
What happened
“As the treatment was started, the machine shut down, giving the operator
an error code labeled “Malfunction 54.” The meaning of this code was not
identified in the manual that came with the machine. The machine also showed a
‘Treatment Pause’ and an underdose, indicating that only about 3% of the
requested dose had been delivered. Thinking that the treatment was
incomplete, the operator told the machine to proceed, but it immediately shut
down again. Because the video monitor was not working, the operator was
unable to see the patient and didn’t know that after the first dose”

Essentially, the operator received the wrong message and continue to give
treatment to the patient even after
why
A "bug" in the software caused the issue. Operators
could enter treatment data quickly, but the hardware
needed time to adjust. If the operator made a mistake
and corrected it rapidly, the software wouldn't wait for
the hardware to catch up before delivering the
incorrect dose.
“From the start, the Therac-25 was designed to be
controlled by software and did not incorporate the level
of hardware safety devices found on the early
machines.”
How
Two factors were to blame:
Systems engineering: The Therac-25 relied solely
on software for safety, lacking essential hardware
safeguards like those in previous models.

Software engineering: The software development


process had flaws, including inadequate
documentation and testing, which allowed the bug
to remain undetected.
Conclusion

Clear user interfaces are Being extra careful is never


essential: redundant:

The Therac-25's error codes confused operators The Therac-25 lacked hardware safeguards that
So user interfaces should provide clear feedback and previous models had, making it vulnerable to
error messages. software bugs.
The user manual also has to include every So, we have to have redundant safety measures,
malfunction messages hardware safeguards in this case
References

An investigation of theRAc-25 accidents - I. (n.d.).


https://web.mit.edu/6.033/2004/wwwdocs/papers/Therac_1.html#:~:text=Between%20June%201985%20a
nd%20January%201987%2C%20six%20known,in%20the%2035-
year%20history%20of%20medical%20accelerators.%20
Thank you for
your attention

You might also like