Incident: Failure to Detect Breast Cancer: Radiologist's Software Failure Incident

Published Date: 2022-11-20

Postmortem Analysis
Timeline 1. The software failure incident involving Dr. Mark Guilfoyle missing breast cancer diagnoses in 24 cases over a three-year period happened over the span of several years, with complaints being made several years ago and a settlement with the New Hampshire Board of Medicine reached in September 2019 [135020]. 2. Estimation: - Step 1: The settlement with the New Hampshire Board of Medicine was reached in September 2019. - Step 2: The article was published on 2022-11-20. - Step 3: The incident likely occurred between 2016 and 2019.
System unknown
Responsible Organization 1. Dr. Mark Guilfoyle, the radiologist who missed breast cancer diagnoses in 24 cases over a three-year period, was responsible for causing the software failure incident [135020]. 2. The New Hampshire Board of Medicine, which settled with Guilfoyle in September 2019 and imposed sanctions that allowed him to keep his license despite the missed diagnoses, was also responsible for the software failure incident [135020].
Impacted Organization 1. Patients who had their mammograms misread by Dr. Mark Guilfoyle, leading to missed breast cancer diagnoses and delayed treatment [135020, 135020]. 2. The New Hampshire Board of Medicine, which faced criticism for its handling of complaints against Dr. Guilfoyle and its lack of transparency in disclosing information about physicians' past malpractice settlements, disciplinary actions, or criminal convictions [135020].
Software Causes unknown
Non-software Causes 1. Delayed response and lack of action by the New Hampshire Board of Medicine in addressing complaints and disciplinary actions against Dr. Mark Guilfoyle [135020] 2. Failure of the New Hampshire medical board to provide transparency regarding physicians' past records, including malpractice settlements, hospital disciplinary actions, and criminal convictions [135020]
Impacts 1. Delayed breast cancer diagnoses in 24 women over a three-year period, leading to some women undergoing mastectomies and radiation treatment [135020] 2. Patients affected by missed breast cancer diagnoses had to undergo further testing and treatment if required [135020] 3. Concerns over the missed diagnoses led to a review of every single mammogram and breast ultrasound interpreted by the radiologist, involving more than 5,500 patient visits [135020] 4. 11 of the affected women settled malpractice claims in 2020, alleging delayed diagnoses of their breast cancer due to the radiologist's negligence [135020]
Preventions 1. Implementing a more robust quality assurance process for medical imaging software to ensure accurate interpretation of mammograms and early detection of abnormalities [135020]. 2. Utilizing advanced AI algorithms in medical imaging software to assist radiologists in detecting potential abnormalities and reducing the risk of missed diagnoses [135020]. 3. Enhancing the transparency and accountability of medical boards by providing easy access to information on physicians' past malpractice settlements, hospital disciplinary actions, and criminal convictions to help patients make informed decisions [135020].
Fixes 1. Implementing stricter regulations and oversight mechanisms within the medical board to ensure timely and thorough investigation of complaints and disciplinary actions against healthcare professionals like Dr. Mark Guilfoyle [135020]. 2. Enhancing transparency in the medical field by making information regarding malpractice settlements, hospital disciplinary actions, and criminal convictions of physicians easily accessible to patients [135020]. 3. Implementing regular audits and reviews of radiologists' interpretations of mammograms and other medical imaging to prevent missed diagnoses and improve patient safety [135020].
References 1. The Boston Globe's Spotlight investigation team [135020] 2. Dr. Rebecca Zuurbier, director of breast imaging at Dartmouth Hitchcock Medical Center [135020] 3. Dartmouth spokesperson Audra Burn [135020] 4. Dr. Emily Baker, the current president of the New Hampshire medical board [135020]

Software Taxonomy of Faults

Category Option Rationale
Recurring unknown The articles do not mention any software failure incidents related to the options provided.
Phase (Design/Operation) design Unknown
Boundary (Internal/External) within_system (a) within_system: - The software failure incident in this case is primarily attributed to the radiologist, Dr. Mark Guilfoyle, who missed breast cancer diagnoses in 24 cases over a three-year period [135020]. - The failure was identified through a review of every single mammogram and breast ultrasound interpreted by Guilfoyle, which led to the discovery of the missed diagnoses [135020]. - The incident involved failures in the interpretation of medical imaging results by the radiologist, indicating an internal system failure within the healthcare setting where Guilfoyle practiced [135020]. (b) outside_system: - There is no indication in the articles that the software failure incident was caused by factors originating from outside the system. The primary focus is on the failures within the healthcare system related to the radiologist's missed diagnoses and the subsequent actions taken by the medical board [135020].
Nature (Human/Non-human) human_actions (a) The software failure incident occurring due to non-human actions: - The articles do not mention any software failure incident occurring due to non-human actions. (b) The software failure incident occurring due to human actions: - The failure in this case was primarily due to the radiologist, Dr. Mark Guilfoyle, missing breast cancer diagnoses in 24 cases over a three-year period [135020]. - Dr. Guilfoyle's negligence and failure to spot signs of breast cancer in mammograms or breast ultrasounds led to delayed diagnoses and potentially life-threatening repercussions for the patients involved [135020]. - The delay in responding to complaints and taking disciplinary action against Dr. Guilfoyle by the New Hampshire Board of Medicine was also a contributing factor in this software failure incident [135020].
Dimension (Hardware/Software) unknown (a) The articles do not mention any hardware-related failures that contributed to the incident. (b) The software failure incident in this case was not related to software issues but rather to the failure of a radiologist, Dr. Mark Guilfoyle, to properly diagnose breast cancer in 24 cases over a three-year period. The failure was attributed to the radiologist's mistakes in interpreting mammograms and breast ultrasounds, rather than any software-related issues [135020].
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident in this case does not involve any malicious intent. The failure was due to the radiologist, Dr. Mark Guilfoyle, missing breast cancer diagnoses in 24 cases over a three-year period. This failure was attributed to the radiologist's negligence and incompetence rather than any intentional harm to the system [135020]. (b) The software failure incident is non-malicious as it was caused by the radiologist's failure to accurately interpret mammograms and identify signs of breast cancer in patients. There is no indication in the articles that the failure was a result of any intentional actions to harm the system [135020].
Intent (Poor/Accidental Decisions) unknown The articles do not mention any software failure incident related to poor decisions or accidental decisions. Therefore, the intent of the software failure incident is unknown.
Capability (Incompetence/Accidental) development_incompetence (a) The software failure incident related to development incompetence is evident in the case of Dr. Mark Guilfoyle, a radiologist who missed breast cancer diagnoses in 24 cases over a three-year period. Despite his life-threatening mistakes, Guilfoyle was only fined $750 and allowed to keep his medical license, with restrictions only on reading mammograms in New Hampshire [135020]. (b) The accidental aspect of the software failure incident can be seen in the missed breast cancer diagnoses by Dr. Guilfoyle, where he failed to notice signs of breast cancer in multiple patients' mammograms and ultrasounds over a period of three years. This failure was not intentional but resulted from the radiologist's oversights and errors in interpretation [135020].
Duration unknown The articles do not mention any software failure incident related to either a permanent or temporary duration. Therefore, the duration of the software failure incident is unknown.
Behaviour omission, value, other (a) crash: The software failure incident in the articles does not involve a crash of a system losing state and not performing any of its intended functions [135020]. (b) omission: The software failure incident can be categorized as an omission where the system omitted to perform its intended functions at instances, leading to missed breast cancer diagnoses in 24 cases over a three-year period by the radiologist, Dr. Mark Guilfoyle [135020]. (c) timing: The software failure incident does not align with a timing failure where the system performs its intended functions correctly but too late or too early [135020]. (d) value: The software failure incident can be classified as a value failure where the system performed its intended functions incorrectly, resulting in missed breast cancer diagnoses in multiple patients [135020]. (e) byzantine: The software failure incident does not exhibit a byzantine behavior where the system behaves erroneously with inconsistent responses and interactions [135020]. (f) other: The software failure incident could also be described as a failure due to negligence or incompetence on the part of the radiologist, Dr. Mark Guilfoyle, rather than a specific software-related issue [135020].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence harm (a) death: People lost their lives due to the software failure - The software failure incident involving Dr. Mark Guilfoyle, a radiologist who missed breast cancer diagnoses in 24 cases over a three-year period, led to serious consequences for the patients. For example, one patient, Patricia Eddy, underwent a double mastectomy after her cancer was not detected in multiple mammograms administered under Guilfoyle's care [135020]. - Another patient, Cheryl Jensen, mentioned that the missed diagnoses by Guilfoyle led to her breast cancer being given time to spread, resulting in her having to undergo surgery, chemotherapy, and radiation [135020].
Domain health The software failure incident discussed in the articles is related to the **health** industry. The incident involves a radiologist, Dr. Mark Guilfoyle, who missed breast cancer diagnoses in 24 cases over a three-year period, leading to serious consequences for the affected patients ([135020]). The failure of the system, in this case, refers to the radiologist's interpretation of mammograms and breast ultrasounds, which resulted in missed diagnoses of breast cancer.

Sources

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