This is a statement from PCDOM which I am posting here as the
discussions as the application referred to is PCDOM's PrimaCare and not
> efficiency. During our earlier days of testing the software, we found
> that unqualified freedom to make changes to the source codes were
> based on incorrect preceptions and lack of domain expertise which
> unwittingly led to compromises in patient safety and quality of care.
1985-1987 -- Therac-25 medical accelerator. A radiation therapy device malfunctions and delivers lethal radiation doses at several medical facilities. Based upon a previous design, the Therac-25 was an "improved" therapy system that could deliver two different kinds of radiation: either a low-power electron beam (beta particles) or X-rays. The Therac-25's X-rays were generated by smashing high-power electrons into a metal target positioned between the electron gun and the patient. A second "improvement" was the replacement of the older Therac-20's electromechanical safety interlocks with software control, a decision made because software was perceived to be more reliable.
What engineers didn't know was that both the 20 and the 25 were
built upon an operating system that had been kludged together by a
programmer with no formal training. Because of a subtle bug called a "race condition,"
a quick-fingered typist could accidentally configure the Therac-25 so
the electron beam would fire in high-power mode but with the metal
X-ray target out of position. At least five patients die; others are
Another medical related software bug disaster here:
"November 2000 -- National Cancer Institute, Panama City. In a series of accidents, therapy planning software created by Multidata Systems International, a U.S. firm, miscalculates the proper dosage of radiation for patients undergoing radiation therapy.
Multidata's software allows a radiation therapist to draw on a computer screen the placement of metal shields called "blocks" designed to protect healthy tissue from the radiation. But the software will only allow technicians to use four shielding blocks, and the Panamanian doctors wish to use five.
The doctors discover that they can trick the software by drawing all five blocks as a single large block with a hole in the middle. What the doctors don't realize is that the Multidata software gives different answers in this configuration depending on how the hole is drawn: draw it in one direction and the correct dose is calculated, draw in another direction and the software recommends twice the necessary exposure.
At least eight patients die, while another 20 receive overdoses likely to cause significant health problems. The physicians, who were legally required to double-check the computer's calculations by hand, are indicted for murder."
> PCDOM has a contract with the Malaysian Government, with conditions,
> for its funding on the development of PrimaCare. PCDOM being a
> professional organisation for doctors is concerned that insinuations
> of PCDOM committing impropriety and therefore being unethical in our
> representation were made at this discussion forum.
> When we were requested to submit PCDOM PrimaCare for the award, we had
> informed that we were eligible on those basis. Since then, we had not
> been informed by MNCC that we had breached any rules, except by some
> individuals from the local open source community. PCDOM questions the
> right of individuals or this community to dictate and demand how PCDOM
> should make available its application and to whom. This goes against
> the very ingredient of freedom. PrimaCare is solely targeted to
> doctors, general practitioners to be precise and we are not
> discriminating amongst the GPs. We are also appalled by this statement
> that "having an online demo of open source software, constitutes as
> use, and hence I equate to being a "doctor" in the context".
> In the meantime, PCDOM takes very seriously the following statements
> made here and will study them further. Freedom of speech should be
> responsible and accountable.
> PCDOM has been innovative in coming out with PrimaCare for the local
> doctors, with Molly responsible for its development but she does not
> have the final say in its distribution. Any further comments,
> statements, questions or collaboration proposals should therefore be
> directed to:
> Honorary Secretary,
> Primary Care Doctors' Organisation Malaysia (PCDOM)
> No: 2 Jalan SS 3/31
> University Garden
> 47300 Petaling Jaya
> or e-mail: email@example.com <mailto:firstname.lastname@example.org>