Cautionary Tales with Tim Harford "Captain Kirk Forgot to put the Machine on Stun"
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Jul 18, 2025 Discover the harrowing story of Voyne Ray Cox, who endured severe burns from the malfunctioning Therac-25 radiation machine. Delve into the systemic failures and human errors that led to tragic outcomes in patient care. The podcast also reflects on the historical origins of software bugs and emphasizes the critical importance of thorough oversight in decision-making, ensuring safety in medical technologies. It's a cautionary tale that highlights the delicate balance between innovation and the perils of technology in healthcare.
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Ray Cox's Radiation Overdose
- Voin Ray Cox suffered multiple severe radiation overdoses during cancer treatment with the Therac-25 machine.
- Operators couldn't hear or see his pain because the control room wasn't linked by audio or video that day.
Risk From Dual-Purpose Design
- The Therac-25's dual-purpose design combined electron and X-ray modes controlled entirely by software.
- A single computer glitch could cause deadly overdoses due to missing hardware interlocks.
Early Radiation Burn Cases Ignored
- Patients like Katie Yarbrough and Frances Hill were burned by radiation overdoses due to Therac-25 malfunctions.
- Injuries were initially misdiagnosed or ignored because AECL manufacturers failed to communicate incidents.
